Provider Demographics
NPI:1992154033
Name:LEGACY DENTAL SA PC
Entity type:Organization
Organization Name:LEGACY DENTAL SA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:ECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-492-0205
Mailing Address - Street 1:13205 GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-3018
Mailing Address - Country:US
Mailing Address - Phone:210-492-0205
Mailing Address - Fax:210-492-0305
Practice Address - Street 1:13205 GEORGE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3018
Practice Address - Country:US
Practice Address - Phone:210-492-0205
Practice Address - Fax:210-492-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty