Healthcare Provider Details

I. General information

NPI: 1720158496
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS SAN ANTONIO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17700 SAN PEDRO AVE SUITE 320
SAN ANTONIO TX
78232-1404
US

IV. Provider business mailing address

8415 DATAPOINT DR SUITE 1020
SAN ANTONIO TX
78229-3298
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-6255
  • Fax: 210-495-6260
Mailing address:
  • Phone: 714-578-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number20569
License Number StateTX

VIII. Authorized Official

Name: DR. MARCUS ERVIN
Title or Position: OWNER
Credential: DDS
Phone: 210-653-4867