MEDICARE: DR PHIL'S FAMILY DENTAL CARE, 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	18397	TX

General Provider Information

NPI Number	:	1073708350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR PHIL'S FAMILY DENTAL CARE, PLLC

Provider Business Mailing Address
First Line	:	8008 WEST AVE
Second Line	:	SUITE 1
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1872
Country	:	US
Telephone Number	:	210-231-0423
Fax Number	:

Provider Business Practice Location Address
First Line	:	8008 WEST AVE
Second Line	:	SUITE 1
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1872
Country	:	US
Telephone Number	:	210-231-0423
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PHILIP L TETZ
Credential	:	D.D.S.
Telephone Number	:	210-231-0430

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	05/29/2008

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