MEDICARE: FIVE STAR FAMILY DENTAL, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1558961540
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	12991 POTRANCO RD STE 107
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-7105
Country	:	US
Telephone Number	:	210-455-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	12991 POTRANCO RD STE 107
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-7105
Country	:	US
Telephone Number	:	210-455-1110
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROGER BRANDON JR.
Credential	:	DDS
Telephone Number	:	210-455-1110

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	11/06/2020

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