Provider Demographics
NPI:1417337684
Name:FUENTES, MARY GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:GRACE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:CAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:10730 POTRANCO RD STE 111
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3330
Mailing Address - Country:US
Mailing Address - Phone:210-495-2000
Mailing Address - Fax:
Practice Address - Street 1:10730 POTRANCO RD STE 111
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3330
Practice Address - Country:US
Practice Address - Phone:210-495-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30929122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist