MEDICARE: WESTLAKES FAMILY DENTAL, PA

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	261QD0000X	Dental Clinic/Center
2	1223G0001X	General Practice Dentistry	20528	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1801818364	OTHER	TX	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1396011839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTLAKES FAMILY DENTAL, PA

Provider Business Mailing Address
First Line	:	9522 POTRANCO RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9601
Country	:	US
Telephone Number	:	210-675-9200
Fax Number	:	210-521-9204

Provider Business Practice Location Address
First Line	:	9522 POTRANCO RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9601
Country	:	US
Telephone Number	:	210-675-9200
Fax Number	:	210-521-9204

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. KERRY W NELSON
Credential	:	DDS
Telephone Number	:	210-675-9200

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	08/06/2020

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Directions to “WESTLAKES FAMILY DENTAL, PA ” Practice Location

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