Provider Demographics
NPI:1063532067
Name:MACIAS, CHARLES ROGER JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROGER
Last Name:MACIAS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:21 SPURS LN
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1634
Mailing Address - Country:US
Mailing Address - Phone:210-614-2020
Mailing Address - Fax:210-694-5099
Practice Address - Street 1:21 SPURS LN
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1634
Practice Address - Country:US
Practice Address - Phone:210-614-2020
Practice Address - Fax:210-694-5099
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX136501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice