Provider Demographics
NPI:1255628582
Name:SAN PEDRO SMILES P.A.
Entity type:Organization
Organization Name:SAN PEDRO SMILES P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER -DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-737-6900
Mailing Address - Street 1:5101 SAN PEDRO AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1461
Mailing Address - Country:US
Mailing Address - Phone:210-737-6900
Mailing Address - Fax:210-737-6904
Practice Address - Street 1:5101 SAN PEDRO AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1461
Practice Address - Country:US
Practice Address - Phone:210-737-6900
Practice Address - Fax:210-737-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty