MEDICARE: COSMETIC DENTISTRY OF SAN ANTONIO

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	1223D0001X	Public Health Dentistry
2	122300000X	Dentist

General Provider Information

NPI Number	:	1487174280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSMETIC DENTISTRY OF SAN ANTONIO

Provider Business Mailing Address
First Line	:	16535 HUEBNER RD STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78248-1676
Country	:	US
Telephone Number	:	210-493-9944
Fax Number	:	210-493-9946

Provider Business Practice Location Address
First Line	:	16535 HUEBNER RD STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78248-1676
Country	:	US
Telephone Number	:	210-493-9944
Fax Number	:	210-493-9946

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	MRS. ASHLEY J GONZALEZ
Credential	:
Telephone Number	:	210-493-9944

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	07/21/2022

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Directions to “COSMETIC DENTISTRY OF SAN ANTONIO ” Practice Location

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