=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285288449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUTUMN CASTILLO DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 07/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1251 AUSTIN HWY STE 104
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-817-8683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6155 ECKHERT RD APT 6104
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78240-3179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-207-6594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 35580
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------