=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780038679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAUTICAL DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2016
-----------------------------------------------------
Last Update Date | 04/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16414 SAN PEDRO AVE STE 200
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78232-2277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-499-0009
-----------------------------------------------------
Fax | 210-499-0002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16414 SAN PEDRO AVE STE 200
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78232-2277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-499-0009
-----------------------------------------------------
Fax | 210-499-0002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DOLORES FALES
-----------------------------------------------------
Credential | R.D.H.
-----------------------------------------------------
Telephone | 210-499-0009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------