MEDICARE: CARILLION HILLS DENTAL INC

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	122300000X	Dentist	D12868	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D12868	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1912031485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARILLION HILLS DENTAL INC

Provider Business Mailing Address
First Line	:	5837 BABCOCK RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2135
Country	:	US
Telephone Number	:	210-696-1220
Fax Number	:	210-696-6861

Provider Business Practice Location Address
First Line	:	5837 BABCOCK RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2135
Country	:	US
Telephone Number	:	210-696-1220
Fax Number	:	210-696-6861

Authorized Official
Title or Position	:	DENTIST
Name	:	MR. JOHN ARTHUR MOORE JR.
Credential	:	DDS
Telephone Number	:	210-696-1220

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/09/2008

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