MEDICARE: CROWNRIDGE 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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1962028142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWNRIDGE DENTAL

Provider Business Mailing Address
First Line	:	6827 CAMP BULLIS RD STE 302
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78256-1730
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6827 CAMP BULLIS RD STE 302
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78256-1730
Country	:	US
Telephone Number	:	210-538-7500
Fax Number	:	210-569-7750

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTIAN ALEXANDER PHAM
Credential	:
Telephone Number	:	210-538-7500

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/23/2020

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Directions to “CROWNRIDGE DENTAL ” Practice Location

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