Healthcare Provider Details

I. General information

NPI: 1720790041
Provider Name (Legal Business Name): FULL SMILE DENTAL SAN ANTONIO ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11330 POTRANCO RD
SAN ANTONIO TX
78253-7281
US

IV. Provider business mailing address

11330 POTRANCO RD
SAN ANTONIO TX
78253-7281
US

V. Phone/Fax

Practice location:
  • Phone: 210-610-0117
  • Fax:
Mailing address:
  • Phone: 210-610-0117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM GRAVES
Title or Position: OWNER
Credential: DMD
Phone: 210-543-8000