MEDICARE: SAN PEDRO SMILES P. A.

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	261QD0000X	Dental Clinic/Center	22242	TX

General Provider Information

NPI Number	:	1073954228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN PEDRO SMILES P. A.

Provider Business Mailing Address
First Line	:	7254 BLANCO RD STE 207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4930
Country	:	US
Telephone Number	:	210-341-7116
Fax Number	:	210-366-9479

Provider Business Practice Location Address
First Line	:	7254 BLANCO RD STE 207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4930
Country	:	US
Telephone Number	:	210-341-7116
Fax Number	:	210-366-9479

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JUSTIN JOSIAH GONZALEZ
Credential	:	DDS
Telephone Number	:	210-341-7116

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	07/16/2013

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