MEDICARE: DENTAL HEALTH ASSOCIATES OF TEXAS, 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	:	1902209398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HEALTH ASSOCIATES OF TEXAS, PC

Provider Business Mailing Address
First Line	:	937 EVENTIDE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5546
Country	:	US
Telephone Number	:	210-824-0430
Fax Number	:

Provider Business Practice Location Address
First Line	:	937 EVENTIDE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5546
Country	:	US
Telephone Number	:	210-824-0430
Fax Number	:

Authorized Official
Title or Position	:	CRED SUPERVISOR
Name	:	KIM WILSON
Credential	:
Telephone Number	:	217-540-5170

Provider Enumeration Date	:	09/30/2014
Last Update Date	:	09/30/2014

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