MEDICARE: IVY LANE DENTISTRY

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	19612	TX

General Provider Information

NPI Number	:	1467539577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVY LANE DENTISTRY

Provider Business Mailing Address
First Line	:	1073 IVY LN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6061
Country	:	US
Telephone Number	:	210-824-9566
Fax Number	:	210-824-9975

Provider Business Practice Location Address
First Line	:	1073 IVY LN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6061
Country	:	US
Telephone Number	:	210-824-9566
Fax Number	:	210-824-9975

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATTHEW LOUIS WESTERBERG
Credential	:	DDS
Telephone Number	:	210-824-9566

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	04/07/2010

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Directions to “IVY LANE DENTISTRY ” Practice Location

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