MEDICARE: 9590 MARBACH SAN ANTONIO SERVICES, 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	122300000X	Dentist

General Provider Information

NPI Number	:	1215493697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	9590 MARBACH SAN ANTONIO SERVICES, PLLC

Provider Business Mailing Address
First Line	:	9590 MARBACH RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9590 MARBACH RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1825
Country	:	US
Telephone Number	:	210-673-9051
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER C GRUMBOS
Credential	:	DDS
Telephone Number	:	972-360-9944

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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