MEDICARE: EMERGENCY DENTIST OF SAN ANTONIO

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	:	1255047338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERGENCY DENTIST OF SAN ANTONIO

Provider Business Mailing Address
First Line	:	3414 ROOSEVELT AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2606
Country	:	US
Telephone Number	:	108-077-2052
Fax Number	:

Provider Business Practice Location Address
First Line	:	3414 ROOSEVELT AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2606
Country	:	US
Telephone Number	:	210-807-7205
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUMIT GOGNA
Credential	:	DMD
Telephone Number	:	210-807-8205

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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Directions to “EMERGENCY DENTIST OF SAN ANTONIO ” Practice Location

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