# INGRAM MALL DENTAL CENTER, P.L.L.C.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043541741
- **Authorized official:** MS. BERTHA ELIZABETH RODRIGUEZ (REGIONAL MANAGER)
- **Authorized official phone:** (210) 354-4867

## Contact information

- **Practice address:** 6301 NW LOOP 410, L1A, SAN ANTONIO, TX 78238-3824
- **Practice address phone:** (210) 354-4867
- **Practice address fax:** (210) 681-6985
- **Mailing address:** 6301 NW LOOP 410, L1A, SAN ANTONIO, TX 78238-3824
- **Mailing address phone:** (210) 354-4867
- **Mailing address fax:** (210) 681-6985

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 15889 | TX | Yes |

## Other

- **Enumeration date:** 01/19/2010
- **Last updated:** 01/19/2010