MEDICARE: KIMBERLY HANYSAK

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	20325	TX

General Provider Information

NPI Number	:	1124188289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY HANYSAK

Provider Business Mailing Address
First Line	:	1218 SW MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78221-1535
Country	:	US
Telephone Number	:	210-495-6255
Fax Number	:

Provider Business Practice Location Address
First Line	:	17700 SAN PEDRO AVE
Second Line	:	SUITE 320
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1404
Country	:	US
Telephone Number	:	210-495-6255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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Directions to “ KIMBERLY HANYSAK ” Practice Location

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