MEDICARE: DR. SUSAN KAYE PEDOTT DMD

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	1223E0200X	Endodontics	DS030073-L	PA
2	1223E0200X	Endodontics	24500	TX

General Provider Information

NPI Number	:	1063432565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN KAYE PEDOTT DMD

Provider Business Mailing Address
First Line	:	1218 SW MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78221-1535
Country	:	US
Telephone Number	:	610-216-9609
Fax Number	:	281-232-9890

Provider Business Practice Location Address
First Line	:	5020 FM 1960 RD W
Second Line	:	STE. B1
City	:	HOUSTON
State	:	TX
Zip	:	77069-4519
Country	:	US
Telephone Number	:	610-216-9609
Fax Number	:	281-232-9890

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/30/2010

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