MEDICARE: DR. MARY GRACE FUENTES D.D.S.

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	30929	TX
2	1223G0001X	General Practice Dentistry	30929	TX

General Provider Information

NPI Number	:	1417337684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY GRACE FUENTES D.D.S.

Provider Business Mailing Address
First Line	:	10730 POTRANCO RD STE 111
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-3330
Country	:	US
Telephone Number	:	210-495-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	10730 POTRANCO RD STE 111
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-3330
Country	:	US
Telephone Number	:	210-495-2000
Fax Number	:

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

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	07/26/2021

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Directions to “ DR. MARY GRACE FUENTES D.D.S.” Practice Location

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