MEDICARE: DR. JOSE ENRIQUE AREVALO D.D.S

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	32821	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	270018516	OTHER	CA	TAX IDENTIFICATION

General Provider Information

NPI Number	:	1689872251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE ENRIQUE AREVALO D.D.S

Provider Business Mailing Address
First Line	:	1730 SW MILITARY DR STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78221-1400
Country	:	US
Telephone Number	:	210-610-0807
Fax Number	:

Provider Business Practice Location Address
First Line	:	1730 SW MILITARY DR STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78221-1400
Country	:	US
Telephone Number	:	210-610-0807
Fax Number	:

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

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	10/28/2022

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