MEDICARE: ATIQUE ORTHODONTICS, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	22352	TX

General Provider Information

NPI Number	:	1013106731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATIQUE ORTHODONTICS, P.A.

Provider Business Mailing Address
First Line	:	340 TREELINE PARK
Second Line	:	# 1229
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1888
Country	:	US
Telephone Number	:	210-826-7422
Fax Number	:

Provider Business Practice Location Address
First Line	:	2770 E EVANS RD
Second Line	:	SUITE 103
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2752
Country	:	US
Telephone Number	:	210-497-5500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIA ISABEL ATIQUE
Credential	:	DDS
Telephone Number	:	210-497-5500

Provider Enumeration Date	:	10/18/2007
Last Update Date	:	10/18/2007

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