Provider Demographics
NPI:1841290137
Name:NORTHWEST DENTAL MANAGEMENT, PA
Entity type:Organization
Organization Name:NORTHWEST DENTAL MANAGEMENT, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MELLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-687-1133
Mailing Address - Street 1:24200 W IH 10
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1145
Mailing Address - Country:US
Mailing Address - Phone:210-687-1133
Mailing Address - Fax:210-687-1132
Practice Address - Street 1:24200 W IH 10
Practice Address - Street 2:SUITE 112
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1145
Practice Address - Country:US
Practice Address - Phone:210-687-1133
Practice Address - Fax:210-687-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty