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General NPI Number Information
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NPI Number | 1821429820
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Entity Type | Organization
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Legal Business Name | CANYON GOLF FAMILY DENTISTRY
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 03/13/2014
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Provider Practice Location Address
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Address Line | 20210 STONE OAK PKWY 209
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City | SAN ANTONIO
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State | TX
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Zip | 78258
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Country | US
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Telephone | 210-787-2062
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Fax |
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Provider Business Mailing Address
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Address Line | 20210 STONE OAK PKWY TBD
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City | SAN ANTONIO
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State | TX
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Zip | 78258
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Country | US
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Telephone | 210-787-2062
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. BRYAN E SOTO
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Credential | DD.S.
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Telephone | 210-787-2062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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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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