1720462849 NPI number — SOUTHERN DENTAL AT DEERBROOK PLLC

Table of content: (NPI 1720462849)

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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