MEDICARE: DEERFIELD DENTAL

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	19006	TX

General Provider Information

NPI Number	:	1942518626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEERFIELD DENTAL

Provider Business Mailing Address
First Line	:	5999 DE ZAVALA RD STE 122
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2236
Country	:	US
Telephone Number	:	210-408-6000
Fax Number	:	210-561-2599

Provider Business Practice Location Address
First Line	:	14855 BLANCO RD STE 413
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-7731
Country	:	US
Telephone Number	:	210-408-6000
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. IRENE KIANSKY BLAESS
Credential	:
Telephone Number	:	210-445-7915

Provider Enumeration Date	:	09/16/2010
Last Update Date	:	09/16/2010

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Directions to “DEERFIELD DENTAL ” Practice Location

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