Healthcare Provider Details

I. General information

NPI: 1740662477
Provider Name (Legal Business Name): KEVIN COPPOLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 10/26/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8606 VILLAGE DR STE B
SAN ANTONIO TX
78217
US

IV. Provider business mailing address

8606 VILLAGE DR STE B
SAN ANTONIO TX
78217-5506
US

V. Phone/Fax

Practice location:
  • Phone: 210-654-6882
  • Fax: 210-654-0036
Mailing address:
  • Phone: 210-654-6882
  • Fax: 210-654-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30980
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: