MEDICARE: INGRAM HILLS DENTAL, PLLC

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	22167	TX

General Provider Information

NPI Number	:	1063840643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INGRAM HILLS DENTAL, PLLC

Provider Business Mailing Address
First Line	:	4496 CALLAGHAN RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-3400
Country	:	US
Telephone Number	:	210-435-4601
Fax Number	:

Provider Business Practice Location Address
First Line	:	4496 CALLAGHAN RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-3400
Country	:	US
Telephone Number	:	210-435-4601
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. MICHELE M BISHOP
Credential	:	DDS
Telephone Number	:	210-435-4601

Provider Enumeration Date	:	10/17/2013
Last Update Date	:	10/17/2013

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