MEDICARE: GERONIMO CANYON DENTISTRY, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1740127638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERONIMO CANYON DENTISTRY, PC

Provider Business Mailing Address
First Line	:	PO BOX 660041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0041
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	15489 CULEBRA RD STE 201
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-4602
Country	:	US
Telephone Number	:	210-512-1690
Fax Number	:	210-501-1686

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERTO A BENAVIDES
Credential	:	DDS
Telephone Number	:	210-512-1690

Provider Enumeration Date	:	04/30/2026
Last Update Date	:	04/30/2026

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