=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437816949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY HOMETOWN DENTIST AT POTRANCO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12370 POTRANCO RD STE 104
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-4261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-756-0616
-----------------------------------------------------
Fax | 830-239-5670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24200 IH 10 W STE 112
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257-1150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-646-1833
-----------------------------------------------------
Fax | 210-687-1132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. P. CHRISTOPHER BAYS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 808-646-1833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------