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General NPI Number Information
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NPI Number | 1649346263
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Entity Type | Organization
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Legal Business Name | COMMERCE ST FAMILY DENTAL
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Dates
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Enumeration Date | 11/27/2006
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 2522 W COMMERCE ST
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City | SAN ANTONIO
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State | TX
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Zip | 78207
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Country | US
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Telephone | 210-225-4867
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Fax | 210-225-5643
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Provider Business Mailing Address
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Address Line | 2522 W COMMERCE ST
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City | SAN ANTONIO
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State | TX
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Zip | 78207
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Country | US
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Telephone | 210-225-4867
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Fax | 210-225-5643
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Authorized Official
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Title or Position | CEO PRESIDENT CHAIRMAN OF BOARD
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Name | DR. ALFRED GWINN BRADFORD JR.
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Credential | DDS
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Telephone | 210-225-4867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 08923
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License Number State | TX
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