=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013739143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JURICH BROTHERS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1804 BUENA VISTA ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78207-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-227-9921
-----------------------------------------------------
Fax | 210-223-4081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1804 BUENA VISTA ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78207-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-227-9921
-----------------------------------------------------
Fax | 210-223-4081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FRONT OFFICE
-----------------------------------------------------
Name | MELANIE RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-227-9921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------