Basic Information
| Provider Information | |||||||||
| NPI: | 1932436326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMPOS FAMILY DENTAL, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6140 WURZBACH ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105236188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6140 WURZBACH ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105236188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2009 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | CAMPOS | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105236188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 16042 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 173412101 | 05 | TX | MEDICAID |