MEDICARE: DR. NICHOLAS DYBDAL-HARGREAVES DDS, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	35211	TX

General Provider Information

NPI Number	:	1033763438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS DYBDAL-HARGREAVES DDS, PHD

Provider Business Mailing Address
First Line	:	10103 W LOOP 1604 N STE 104
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-9716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10103 W LOOP 1604 N STE 104
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-9716
Country	:	US
Telephone Number	:	210-495-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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