MEDICARE: VALUDENTAL WALZEM1 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	122300000X	Dentist	25764	TX

General Provider Information

NPI Number	:	1396255469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALUDENTAL WALZEM1 PLLC

Provider Business Mailing Address
First Line	:	5201 WALZEM RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218
Country	:	US
Telephone Number	:	210-686-0749
Fax Number	:	210-233-8859

Provider Business Practice Location Address
First Line	:	5201 WALZEM RD
Second Line	:
City	:	WINDCREST
State	:	TX
Zip	:	78218-2122
Country	:	US
Telephone Number	:	210-686-0749
Fax Number	:	281-533-6130

Authorized Official
Title or Position	:	OWNER
Name	:	BRADLEY MICHAEL SMITH
Credential	:	DDS
Telephone Number	:	210-686-0749

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	02/13/2020

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