MEDICARE: KELSEY BETH PENA GARZA DDS

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	33021	TX

General Provider Information

NPI Number	:	1801326244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY BETH PENA GARZA DDS

Provider Business Mailing Address
First Line	:	4715 SHAVANO CT
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-5889
Country	:	US
Telephone Number	:	210-385-1347
Fax Number	:

Provider Business Practice Location Address
First Line	:	24200 IH 10 W STE 112
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1150
Country	:	US
Telephone Number	:	210-687-1133
Fax Number	:

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

Provider Enumeration Date	:	06/18/2017
Last Update Date	:	02/03/2019

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