MEDICARE: DE ZAVALA DENTISTRY AND ORTHODONTICS 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1205318441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE ZAVALA DENTISTRY AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	5230 DE ZAVALA RD STE 225
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-1731
Country	:	US
Telephone Number	:	210-696-0667
Fax Number	:

Provider Business Practice Location Address
First Line	:	5230 DE ZAVALA RD STE 225
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-1731
Country	:	US
Telephone Number	:	210-696-0667
Fax Number	:

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	MARY PU
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	09/04/2018
Last Update Date	:	05/18/2022

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