=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477740611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOYA FAMILY DENTISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3630 SE MILITARY DR 114
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-337-6834
-----------------------------------------------------
Fax | 210-337-6551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3630 SE MILITARY DR 114
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-337-6834
-----------------------------------------------------
Fax | 210-337-6551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEONARDO MOYA II
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 210-337-6834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 20527
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------