MEDICARE: SOUTH TEXAS DENTAL ASSOCIATES, L.P.

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	16570	TX

General Provider Information

NPI Number	:	1447478847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TEXAS DENTAL ASSOCIATES, L.P.

Provider Business Mailing Address
First Line	:	6300 WEST LOOP S STE 650
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2997
Country	:	US
Telephone Number	:	713-663-7960
Fax Number	:	713-349-8027

Provider Business Practice Location Address
First Line	:	815 E BERRY ST # B
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76110-4414
Country	:	US
Telephone Number	:	817-920-5919
Fax Number	:	817-920-5970

Authorized Official
Title or Position	:	OFFICER/PARTNER
Name	:	BARRY JAMES GOMEL
Credential	:	DDS
Telephone Number	:	713-663-7960

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/07/2011

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