MEDICARE: WINDCREST PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	24209	TX

General Provider Information

NPI Number	:	1982964839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINDCREST PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	5500 WALZEM RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-2103
Country	:	US
Telephone Number	:	210-657-4641
Fax Number	:	210-655-4012

Provider Business Practice Location Address
First Line	:	5500 WALZEM RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-2103
Country	:	US
Telephone Number	:	210-657-4641
Fax Number	:	210-655-4012

Authorized Official
Title or Position	:	OWNER
Name	:	SYLVESTER C. AWAGU
Credential	:	DMD
Telephone Number	:	210-657-4641

Provider Enumeration Date	:	05/25/2012
Last Update Date	:	10/11/2012

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Directions to “WINDCREST PEDIATRIC DENTISTRY ” Practice Location

Language	Start Address	Practice Location

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