Healthcare Provider Details

I. General information

NPI: 1912903444
Provider Name (Legal Business Name): RICHARD DOUGLAS TAVERNA PH.D.,D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

430 W LOOP 1604 N SUITE 109
SAN ANTONIO TX
78251-3342
US

IV. Provider business mailing address

430 W.LOOP 1604 NORTH, SUITE 109
SAN ANTONIO TX
78251
US

V. Phone/Fax

Practice location:
  • Phone: 210-469-3869
  • Fax: 210-402-0025
Mailing address:
  • Phone: 210-647-7447
  • Fax: 210-647-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13696
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: