Provider Demographics
NPI:1881392330
Name:QUEZADA, CARLOS R
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 THOUSAND OAKS DR STE 117
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2300
Mailing Address - Country:US
Mailing Address - Phone:210-492-5668
Mailing Address - Fax:
Practice Address - Street 1:1583 THOUSAND OAKS DR STE 117
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2300
Practice Address - Country:US
Practice Address - Phone:210-492-5668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX395331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program