Healthcare Provider Details

I. General information

NPI: 1609088145
Provider Name (Legal Business Name): CHARLES BARNETT PETERS III D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 FM 3009
SCHERTZ TX
78154-1000
US

IV. Provider business mailing address

16011 HUEBNER CRST
SAN ANTONIO TX
78248-1471
US

V. Phone/Fax

Practice location:
  • Phone: 210-659-2200
  • Fax:
Mailing address:
  • Phone: 210-857-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20838
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: