Provider Demographics
NPI:1073954228
Name:SAN PEDRO SMILES P. A.
Entity Type:Organization
Organization Name:SAN PEDRO SMILES P. A.
Other - Org Name:BLANCO SMILES DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JOSIAH
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-341-7116
Mailing Address - Street 1:7254 BLANCO RD STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4930
Mailing Address - Country:US
Mailing Address - Phone:210-341-7116
Mailing Address - Fax:210-366-9479
Practice Address - Street 1:7254 BLANCO RD STE 207
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4930
Practice Address - Country:US
Practice Address - Phone:210-341-7116
Practice Address - Fax:210-366-9479
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN PEDRO SMILES P. A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22242261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental