=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245648732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERIATRIC DENTAL GROUP OF SOUTH TEXAS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2014
-----------------------------------------------------
Last Update Date | 07/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5282 MEDICAL DR STE 104
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-4983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-617-4446
-----------------------------------------------------
Fax | 210-617-5572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5282 MEDICAL DR STE 104
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-4983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-617-4446
-----------------------------------------------------
Fax | 210-617-5572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. SARAH JUNE DIRKS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 210-617-4446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 16152
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------