MEDICARE: JACK SHIRLEY

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	12068	TX

General Provider Information

NPI Number	:	1376715201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK SHIRLEY

Provider Business Mailing Address
First Line	:	7826 LOUIS PASTEUR, STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7826 LOUIS PASTEUR STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3410
Country	:	US
Telephone Number	:	210-615-8357
Fax Number	:	210-615-8359

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

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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Directions to “ JACK SHIRLEY ” Practice Location

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