Healthcare Provider Details

I. General information

NPI: 1982957122
Provider Name (Legal Business Name): BLANCO FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12042 BLANCO RD SUITE 300
SAN ANTONIO TX
78216-5440
US

IV. Provider business mailing address

12042 BLANCO RD SUITE 300
SAN ANTONIO TX
78216-5440
US

V. Phone/Fax

Practice location:
  • Phone: 210-349-9800
  • Fax: 210-349-9811
Mailing address:
  • Phone: 210-349-9800
  • Fax: 210-349-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN SCOTT
Title or Position: DENTIST
Credential: DDS
Phone: 210-349-9800