Provider Demographics
NPI:1427652932
Name:CITY BASE PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:CITY BASE PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:830-772-5600
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0356
Mailing Address - Country:US
Mailing Address - Phone:956-725-3100
Mailing Address - Fax:
Practice Address - Street 1:2302 SE MILITARY DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3586
Practice Address - Country:US
Practice Address - Phone:830-772-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty