MEDICARE: CELEBRACES COMMERCE 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	24904	TX

General Provider Information

NPI Number	:	1467801423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CELEBRACES COMMERCE PLLC

Provider Business Mailing Address
First Line	:	4965 W COMMERCE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78237-1508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4965 W COMMERCE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78237-1508
Country	:	US
Telephone Number	:	210-451-0000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID B FERGUSON
Credential	:	CAGS
Telephone Number	:	210-683-6353

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	06/09/2016

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