MEDICARE: WILLIAM PANNEBAKER

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	17753	TX

General Provider Information

NPI Number	:	1538229588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM PANNEBAKER

Provider Business Mailing Address
First Line	:	1218 SW MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78221-1535
Country	:	US
Telephone Number	:	210-736-4692
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-2017
Country	:	US
Telephone Number	:	210-736-4692
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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