Provider Demographics
NPI:1477552925
Name:VIZUETE, JACK R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:VIZUETE
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:DEPT. OF ORAL AND MAXILLOFACIAL SURGERY - MC7908
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-567-3470
Mailing Address - Fax:210-567-2995
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:DEPT. OF ORAL AND MAXILLOFACIAL SURGERY - MC7908
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-567-3470
Practice Address - Fax:210-567-2995
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
TX143751223X0400X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306284-03Medicaid
TX742404710OtherTAX ID
TXD14375OtherDELTA TX CHIPS
TX1306284-05Medicaid
TX840368OtherUNITED CONCORDIA
TX840368OtherUNITED CONCORDIA
TX742404710OtherTAX ID
TXT93168Medicare UPIN