MEDICARE: SOUTHEAST ENDODONTIC GROUP PC

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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1588076103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST ENDODONTIC GROUP PC

Provider Business Mailing Address
First Line	:	3303 S WW WHITE RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-4829
Country	:	US
Telephone Number	:	210-257-8863
Fax Number	:	210-257-8940

Provider Business Practice Location Address
First Line	:	3303 S WW WHITE RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-4829
Country	:	US
Telephone Number	:	210-257-8863
Fax Number	:	210-257-8940

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	KARRIEM THURMAN
Credential	:
Telephone Number	:	267-973-5988

Provider Enumeration Date	:	06/02/2014
Last Update Date	:	06/02/2014

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