MEDICARE: VINCENT FONTANA, JR., D.D.S., INC.

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	261QD0000X	Dental Clinic/Center	10506	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TXB113099	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	D10506	OTHER	TX	BLUE CROSS BLUE SHIELD
3	821950	OTHER	TX	UNITED CONCORDIA

General Provider Information

NPI Number	:	1013910009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINCENT FONTANA, JR., D.D.S., INC.

Provider Business Mailing Address
First Line	:	207 W SUNSET RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-2634
Country	:	US
Telephone Number	:	210-826-9523
Fax Number	:	210-826-9524

Provider Business Practice Location Address
First Line	:	207 W SUNSET RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-2634
Country	:	US
Telephone Number	:	210-826-9523
Fax Number	:	210-826-9524

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VINCENT FONTANA JR.
Credential	:	D.D.S.
Telephone Number	:	210-826-9523

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	03/04/2014

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