MEDICARE: S. TEXAS ORTHO PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1144876194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. TEXAS ORTHO PLLC

Provider Business Mailing Address
First Line	:	21970 BULVERDE RD STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2179
Country	:	US
Telephone Number	:	210-493-6067
Fax Number	:

Provider Business Practice Location Address
First Line	:	21970 BULVERDE RD STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2179
Country	:	US
Telephone Number	:	210-493-6067
Fax Number	:

Authorized Official
Title or Position	:	VP INSURANCE PLAN MANAGEMENT
Name	:	MIKE COLE
Credential	:
Telephone Number	:	941-955-3150

Provider Enumeration Date	:	08/15/2019
Last Update Date	:	08/15/2019

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