Organization
EL CENTRO DEL BARRIO INC
Active
Other names
CentroMed South Park Dental
Organization subpart
No
Provider details
NPI number
Authorized official
CHUCK WALZEL (CFO)
(210) 334-3724
Entity
Organization
Contact information
Practice address
910 WAGNER AVE, SAN ANTONIO, TX 78211-3213
(210) 924-7344
(210) 923-7929
Mailing address
3750 COMMERCIAL AVE, SAN ANTONIO, TX 78221-3117
(210) 334-3700
(210) 922-0162
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
HBOCS00758-04-00
TX
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
HBOCS00758-04-00
TX
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
HBOCS007758-04-00
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00MT08
GROUP MEDICARE
TX
05
—
102980101
—
TX
05
—
120980102
—
TX
05
—
120980103
—
TX
05
—
120980105
—
TX
01
—
G60232-02
DELTA DENTAL
TX
Enumeration date
11/09/2007
Last updated
06/01/2012
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