MEDICARE: FREDERICKSBURG SQUARE DENTAL, 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	1223P0221X	Pediatric Dentistry	22842	TX

General Provider Information

NPI Number	:	1497127450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERICKSBURG SQUARE DENTAL, PLLC

Provider Business Mailing Address
First Line	:	145 RANCH DR
Second Line	:
City	:	BOERNE
State	:	TX
Zip	:	78015-8319
Country	:	US
Telephone Number	:	210-326-5546
Fax Number	:

Provider Business Practice Location Address
First Line	:	3949 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-3231
Country	:	US
Telephone Number	:	210-326-5546
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID L KEETON
Credential	:	DDS
Telephone Number	:	210-500-7577

Provider Enumeration Date	:	10/29/2015
Last Update Date	:	09/13/2024

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