Provider Demographics
NPI:1396174900
Name:SOUTHSIDE CHILDRENSA DENTAL CENTER
Entity type:Organization
Organization Name:SOUTHSIDE CHILDRENSA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ZERCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-922-3483
Mailing Address - Street 1:125 SW MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1650
Mailing Address - Country:US
Mailing Address - Phone:210-922-3483
Mailing Address - Fax:
Practice Address - Street 1:125 SW MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1650
Practice Address - Country:US
Practice Address - Phone:210-922-3483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140601223P0221X
WI237051223P0221X
PA252391223P0221X
CA276961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009833701Medicaid
TX209944201Medicaid
TX204974401Medicaid
TX2882862Medicaid
TX126722102Medicaid