Provider Demographics
NPI:1053136432
Name:ALTA VISTA DENTISTRY PLLC
Entity type:Organization
Organization Name:ALTA VISTA DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-734-6556
Mailing Address - Street 1:405 W GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2827
Mailing Address - Country:US
Mailing Address - Phone:210-734-6556
Mailing Address - Fax:
Practice Address - Street 1:405 W GRAMERCY PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2827
Practice Address - Country:US
Practice Address - Phone:210-734-6556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty