1720462849 NPI number — SOUTHERN DENTAL AT DEERBROOK PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720462849 NPI number — SOUTHERN DENTAL AT DEERBROOK PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN DENTAL AT DEERBROOK PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720462849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8000 W. INTERSTATE 10
Provider Second Line Business Mailing Address:
SUITE 407
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-774-4588
Provider Business Mailing Address Fax Number:
210-640-5995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20131 HWY 59 N
Provider Second Line Business Practice Location Address:
SUITE 1238
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-445-4237
Provider Business Practice Location Address Fax Number:
281-446-6942
Provider Enumeration Date:
07/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WINGFIELD
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
210-794-4588

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  30690 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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