Healthcare Provider Details

I. General information

NPI: 1023831310
Provider Name (Legal Business Name): EADO FAMILY DENTAL - NORTHSIDE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 PINEMONT DR STE I
HOUSTON TX
77018-1323
US

IV. Provider business mailing address

2607 CLAY ST
HOUSTON TX
77003-4516
US

V. Phone/Fax

Practice location:
  • Phone: 917-331-3281
  • Fax:
Mailing address:
  • Phone: 917-331-3281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN WILSON MA
Title or Position: OWNER
Credential:
Phone: 917-331-3281