=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275336059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVERSE FAMILY COSMETIC & IMPLANT DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2025
-----------------------------------------------------
Last Update Date | 03/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9160 FM 78 STE 1B
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-607-5566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7228 BANDERA RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78238-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-898-8601
-----------------------------------------------------
Fax | 210-756-9161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIAL/ HUMAN RESOURCE MANAGER
-----------------------------------------------------
Name | MS. RITA OLAFUSI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-898-8601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------