Healthcare Provider Details

I. General information

NPI: 1487174280
Provider Name (Legal Business Name): COSMETIC DENTISTRY OF SAN ANTONIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16535 HUEBNER RD STE 102
SAN ANTONIO TX
78248-1676
US

IV. Provider business mailing address

16535 HUEBNER RD STE 102
SAN ANTONIO TX
78248-1676
US

V. Phone/Fax

Practice location:
  • Phone: 210-493-9944
  • Fax: 210-493-9946
Mailing address:
  • Phone: 210-493-9944
  • Fax: 210-493-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ASHLEY J GONZALEZ
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 210-493-9944