Basic Information
| Provider Information | |||||||||
| NPI: | 1467801423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CELEBRACES COMMERCE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4965 W COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782371508 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4965 W COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782371508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104510000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | FERGUSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2106836353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CAGS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 24904 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.