Healthcare Provider Details

I. General information

NPI: 1699737825
Provider Name (Legal Business Name): STEPHEN RICHARD GASPAROVICH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 TRUEMPER ST
JBSA LACKLAND TX
78236-5511
US

IV. Provider business mailing address

2133 KLINKER STREET, BLDG 3352 AIR FORCE POSTGRADUATE DENTAL SCHOOL
JBSA LACKLAND TX
78236-5313
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-0123
  • Fax:
Mailing address:
  • Phone: 210-292-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30022122
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number33675
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: