Provider Demographics
NPI:1902029077
Name:CALVERLEY, MICKEY JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:JOE
Last Name:CALVERLEY
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 1:1314 E SONTERRA BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4278
Mailing Address - Country:US
Mailing Address - Phone:210-308-8211
Mailing Address - Fax:210-308-0650
Practice Address - Street 1:1314 E SONTERRA BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4278
Practice Address - Country:US
Practice Address - Phone:210-308-8211
Practice Address - Fax:210-308-0650
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106781223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics