Provider Demographics
NPI:1174929707
Name:MENCHACA, ANTONIO JOSE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:JOSE
Last Name:MENCHACA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3680
Mailing Address - Country:US
Mailing Address - Phone:714-337-3459
Mailing Address - Fax:
Practice Address - Street 1:711 W 38TH ST STE E4
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1132
Practice Address - Country:US
Practice Address - Phone:512-479-6633
Practice Address - Fax:512-479-6617
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9137998-99211223G0001X
TX336501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice