MEDICARE: DR. JACK R. VIZUETE DDS

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	14375	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	14375	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	742404710	OTHER	TX	TAX ID
3	D14375	OTHER	TX	DELTA TX CHIPS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	840368	OTHER	TX	UNITED CONCORDIA

General Provider Information

NPI Number	:	1477552925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK R. VIZUETE DDS

Provider Business Mailing Address
First Line	:	7703 FLOYD CURL DR
Second Line	:	DEPT. OF ORAL AND MAXILLOFACIAL SURGERY - MC7908
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3901
Country	:	US
Telephone Number	:	210-567-3470
Fax Number	:	210-567-2995

Provider Business Practice Location Address
First Line	:	7703 FLOYD CURL DR
Second Line	:	DEPT. OF ORAL AND MAXILLOFACIAL SURGERY - MC7908
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3901
Country	:	US
Telephone Number	:	210-567-3470
Fax Number	:	210-567-2995

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	03/07/2023

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