=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013910009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINCENT FONTANA, JR., D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 W SUNSET RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-826-9523
-----------------------------------------------------
Fax | 210-826-9524
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 W SUNSET RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-826-9523
-----------------------------------------------------
Fax | 210-826-9524
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VINCENT FONTANA JR.
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 210-826-9523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 10506
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------