MEDICARE: NORIEGA DENTAL GROUP 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

General Provider Information

NPI Number	:	1114742236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORIEGA DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	4315 MOONLIGHT WAY STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1690
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 MOONLIGHT WAY STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1690
Country	:	US
Telephone Number	:	210-263-3838
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	CARLOS QUEZADA
Credential	:	DDS
Telephone Number	:	956-438-2073

Provider Enumeration Date	:	11/22/2024
Last Update Date	:	11/22/2024

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