Provider Demographics
NPI:1801594924
Name:DEROSA, CHRISTINE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:MARIE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4615 GARDENDALE ST APT 2408
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4235
Mailing Address - Country:US
Mailing Address - Phone:210-740-5536
Mailing Address - Fax:
Practice Address - Street 1:902 KITTY HAWK RD STE 100
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3962
Practice Address - Country:US
Practice Address - Phone:210-566-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41533122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program