MEDICARE: KIDDO DENAL PA

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	1223P0221X	Pediatric Dentistry	23041	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841580826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDDO DENAL PA

Provider Business Mailing Address
First Line	:	3520 S. NEW BRAUNFELS STE 100
Second Line	:	KIDDO DENTAL
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223
Country	:	US
Telephone Number	:	210-532-3040
Fax Number	:	210-532-2105

Provider Business Practice Location Address
First Line	:	3520 S. NEW BRAUNFELS STE 100
Second Line	:	KIDDO DENTAL
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223
Country	:	US
Telephone Number	:	210-532-3040
Fax Number	:	210-532-2105

Authorized Official
Title or Position	:	DENTIST
Name	:	CESAR ROTTER
Credential	:	DDS
Telephone Number	:	210-532-3040

Provider Enumeration Date	:	04/12/2011
Last Update Date	:	04/12/2011

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