MEDICARE: SHAVANO PARK FAMILY DENTISTRY, 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	122300000X	Dentist	21004	TX

General Provider Information

NPI Number	:	1942359286
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAVANO PARK FAMILY DENTISTRY, PA

Provider Business Mailing Address
First Line	:	4466 LOCKHILL SELMA RD
Second Line	:	STE. 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2078
Country	:	US
Telephone Number	:	210-764-8600
Fax Number	:	210-764-0844

Provider Business Practice Location Address
First Line	:	4466 LOCKHILL SELMA RD
Second Line	:	STE. 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2078
Country	:	US
Telephone Number	:	210-764-8600
Fax Number	:	210-764-0844

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HUYEN ALLISON TRAN
Credential	:	DDS
Telephone Number	:	210-764-8600

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	08/22/2020

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