Healthcare Provider Details

I. General information

NPI: 1770915829
Provider Name (Legal Business Name): CARLOS GABRIEL LANDAETA QUINONES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-567-3460
  • Fax:
Mailing address:
  • Phone: 210-567-3297
  • Fax: 210-567-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30389
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: