Provider Demographics
NPI:1134300395
Name:JANSE, CAM RIDDICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAM
Middle Name:RIDDICK
Last Name:JANSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9820 BRAUN RD., SUITE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254
Mailing Address - Country:US
Mailing Address - Phone:210-523-2400
Mailing Address - Fax:210-523-2401
Practice Address - Street 1:9820 BRAUN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254
Practice Address - Country:US
Practice Address - Phone:210-523-2400
Practice Address - Fax:210-523-2401
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120845604Medicaid