MEDICARE: MODERN DENTAL PROFESSIONALS SAN ANTONIO PC

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	20569	TX

General Provider Information

NPI Number	:	1720158496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS SAN ANTONIO PC

Provider Business Mailing Address
First Line	:	8415 DATAPOINT DR
Second Line	:	SUITE 1020
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3298
Country	:	US
Telephone Number	:	714-578-6358
Fax Number	:

Provider Business Practice Location Address
First Line	:	17700 SAN PEDRO AVE
Second Line	:	SUITE 320
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1404
Country	:	US
Telephone Number	:	210-495-6255
Fax Number	:	210-495-6260

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARCUS ERVIN
Credential	:	DDS
Telephone Number	:	210-653-4867

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	12/07/2016

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