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General NPI Number Information
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NPI Number | 1770225658
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Entity Type | Organization
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Legal Business Name | TEXAS DENTAL SPECIALIST PRACTICE, PLLC
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Dates
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Enumeration Date | 04/11/2022
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 1202 W BITTERS RD BLDG 6
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City | SAN ANTONIO
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State | TX
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Zip | 78216-7852
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Country | US
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Telephone | 210-491-0015
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Fax |
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Provider Business Mailing Address
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Address Line | 6110 BARNES RD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80922-2600
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DATA ANALYST
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Name | GREGORY KOSTELAC
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Credential |
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Telephone | 719-372-5605
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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 |
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License Number State |
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