MEDICARE: SAN PEDRO SMILES P.A.

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	22242	TX

General Provider Information

NPI Number	:	1255628582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN PEDRO SMILES P.A.

Provider Business Mailing Address
First Line	:	5101 SAN PEDRO AVE
Second Line	:	SUITE 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-1461
Country	:	US
Telephone Number	:	210-737-6900
Fax Number	:	210-737-6904

Provider Business Practice Location Address
First Line	:	5101 SAN PEDRO AVE
Second Line	:	SUITE 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-1461
Country	:	US
Telephone Number	:	210-737-6900
Fax Number	:	210-737-6904

Authorized Official
Title or Position	:	OWNER -DENTIST
Name	:	DR. JUSTIN J GONZALEZ
Credential	:	DDS
Telephone Number	:	210-737-6900

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	07/07/2011

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