Healthcare Provider Details

I. General information

NPI: 1528332004
Provider Name (Legal Business Name): ROBERTO L VILLARREALDDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 S GENERAL MCMULLEN DR STE 102
SAN ANTONIO TX
78237-4200
US

IV. Provider business mailing address

1302 S GENERAL MCMULLEN DR STE 102
SAN ANTONIO TX
78237-4200
US

V. Phone/Fax

Practice location:
  • Phone: 210-432-7851
  • Fax: 210-432-1157
Mailing address:
  • Phone: 210-432-7851
  • Fax: 210-432-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number22476
License Number StateTX

VIII. Authorized Official

Name: DR. ROBERTO LUIS VILLARREAL
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 210-432-7851