MEDICARE: VAN DE WALLE FAMILY DENTISTRY

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	21761	TX

General Provider Information

NPI Number	:	1649536244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN DE WALLE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	111 WILLOWS SPRINGS DR
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-6076
Country	:	US
Telephone Number	:	512-878-2540
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 WILLOWS SPRINGS DR.
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-6076
Country	:	US
Telephone Number	:	512-878-2540
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS VAN DE WALLE
Credential	:
Telephone Number	:	512-878-2540

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	06/02/2016

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