MEDICARE: SAN ANTONIO PEDIATRIC DENTISTRY, PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1427513316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANTONIO PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	1320 WONDER WORLD DR STE 103
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-7558
Country	:	US
Telephone Number	:	210-944-8111
Fax Number	:

Provider Business Practice Location Address
First Line	:	17026 BULVERDE RD STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-4700
Country	:	US
Telephone Number	:	210-944-8111
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CLAUDIA RAINS
Credential	:
Telephone Number	:	512-353-5500

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	07/24/2020

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