MEDICARE: DON RAY PETTY DDS

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	1223G0001X	General Practice Dentistry	38802	TX
2	122300000X	Dentist	38802	TX

General Provider Information

NPI Number	:	1144956137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DON RAY PETTY DDS

Provider Business Mailing Address
First Line	:	12303 FORT CHADBORNE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-4433
Country	:	US
Telephone Number	:	210-995-5123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2358 E SOUTHCROSS BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-2263
Country	:	US
Telephone Number	:	210-364-2561
Fax Number	:

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

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	09/26/2024

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