Provider Demographics
NPI:1609093939
Name:ORTHOGENESIS INTERNATIONAL CENTRE SOUTH, PA
Entity type:Organization
Organization Name:ORTHOGENESIS INTERNATIONAL CENTRE SOUTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NELIA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:GARCIA-MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:956-717-9877
Mailing Address - Street 1:6410 MCPHERSON RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6191
Mailing Address - Country:US
Mailing Address - Phone:956-717-9877
Mailing Address - Fax:956-717-9881
Practice Address - Street 1:6410 MCPHERSON RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6191
Practice Address - Country:US
Practice Address - Phone:956-717-9877
Practice Address - Fax:956-717-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207181223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160748301Medicaid
TX163924701Medicaid