=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871754978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDS SMILE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2008
-----------------------------------------------------
Last Update Date | 06/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 N SAN SABA SUITE #1220
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78207-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-225-8888
-----------------------------------------------------
Fax | 210-225-4195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 N SAN SABA SUITE#1220
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78207-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-225-8888
-----------------------------------------------------
Fax | 210-225-4195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAURICIO MARCUSHAMER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 210-225-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 18580
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------