MEDICARE: SOUTH TEXAS DENTAL ASSOCIATES, LP

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	16570	TX

General Provider Information

NPI Number	:	1689015505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TEXAS DENTAL ASSOCIATES, LP

Provider Business Mailing Address
First Line	:	6300 WEST LOOP S STE 650
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2997
Country	:	US
Telephone Number	:	713-457-3445
Fax Number	:

Provider Business Practice Location Address
First Line	:	2482 JACKSBORO HWY
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76114-2201
Country	:	US
Telephone Number	:	817-626-4867
Fax Number	:

Authorized Official
Title or Position	:	OFFICER/PARTNER
Name	:	DR. BARRY GOMEL
Credential	:	DDS
Telephone Number	:	713-457-3445

Provider Enumeration Date	:	07/08/2013
Last Update Date	:	07/08/2013

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