Basic Information
| Provider Information | |||||||||
| NPI: | 1316334113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAS PALMAS DENTAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674330 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408081970 | ||||||||
| FaxNumber: | 8557315147 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 S GENERAL MCMULLEN DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782373111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408081970 | ||||||||
| FaxNumber: | 8557315147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCKENZIE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9408081970 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 27638 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.