MEDICARE: DR. THADDEUS MILES CHAMBERLAIN 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	07519	IA

General Provider Information

NPI Number	:	1831181098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THADDEUS MILES CHAMBERLAIN DDS

Provider Business Mailing Address
First Line	:	21142 SANTA LUCIA
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2173
Country	:	US
Telephone Number	:	210-565-0647
Fax Number	:	210-565-4240

Provider Business Practice Location Address
First Line	:	21142 SANTA LUCIA
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2173
Country	:	US
Telephone Number	:	210-565-0647
Fax Number	:	210-565-4240

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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