MEDICARE: ODES ROBERTSON

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12381	TX

General Provider Information

NPI Number	:	1922168996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODES ROBERTSON

Provider Business Mailing Address
First Line	:	1202 E SONTERRA BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4089
Country	:	US
Telephone Number	:	210-494-2005
Fax Number	:

Provider Business Practice Location Address
First Line	:	18850 STONE OAK PKWY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4113
Country	:	US
Telephone Number	:	210-499-0303
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	03/31/2016

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Directions to “ ODES ROBERTSON ” Practice Location

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