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General NPI Number Information
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NPI Number | 1073954228
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Entity Type | Organization
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Legal Business Name | SAN PEDRO SMILES P. A.
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Dates
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Enumeration Date | 07/16/2013
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Last Update Date | 07/16/2013
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Provider Practice Location Address
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Address Line | 7254 BLANCO RD STE 207
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City | SAN ANTONIO
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State | TX
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Zip | 78216-4930
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Country | US
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Telephone | 210-341-7116
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Fax | 210-366-9479
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Provider Business Mailing Address
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Address Line | 7254 BLANCO RD STE 207
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City | SAN ANTONIO
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State | TX
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Zip | 78216-4930
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Country | US
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Telephone | 210-341-7116
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Fax | 210-366-9479
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUSTIN JOSIAH GONZALEZ
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Credential | DDS
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Telephone | 210-341-7116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 22242
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License Number State | TX
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