Healthcare Provider Details

I. General information

NPI: 1598027179
Provider Name (Legal Business Name): WDMG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9125 WEST RD
HOUSTON TX
77064-8623
US

IV. Provider business mailing address

9125 WEST RD
HOUSTON TX
77064-8623
US

V. Phone/Fax

Practice location:
  • Phone: 713-937-0050
  • Fax: 713-937-0518
Mailing address:
  • Phone: 281-893-1060
  • Fax: 281-893-6807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19503
License Number StateTX

VIII. Authorized Official

Name: JONATHAN LOUIS LEPOW
Title or Position: PRESIDENT
Credential:
Phone: 713-937-0050