MEDICARE: CARLOS R. QUEZADA

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	39533	TX

General Provider Information

NPI Number	:	1881392330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS R. QUEZADA

Provider Business Mailing Address
First Line	:	1583 THOUSAND OAKS DR STE 117
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-2300
Country	:	US
Telephone Number	:	210-492-5668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1583 THOUSAND OAKS DR STE 117
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-2300
Country	:	US
Telephone Number	:	210-492-5668
Fax Number	:

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

Provider Enumeration Date	:	02/22/2023
Last Update Date	:	07/17/2023

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Directions to “ CARLOS R. QUEZADA ” Practice Location

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