=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720158496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN DENTAL PROFESSIONALS SAN ANTONIO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 12/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17700 SAN PEDRO AVE SUITE 320
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78232-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-495-6255
-----------------------------------------------------
Fax | 210-495-6260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8415 DATAPOINT DR SUITE 1020
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-578-6358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARCUS ERVIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 210-653-4867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 20569
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------