Provider First Line Business Practice Location Address:
2410 STANLEY RD
Provider Second Line Business Practice Location Address:
DENTAC SUITE 200H
Provider Business Practice Location Address City Name:
FORT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-7529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-295-2743
Provider Business Practice Location Address Fax Number:
210-295-2602
Provider Enumeration Date:
08/11/2006