Healthcare Provider Details

I. General information

NPI: 1750306817
Provider Name (Legal Business Name): TANYA LYNN WOODY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

2200 BERGQUIST DR STE 1 ATTN: CREDENTIALS (CMC)
LACKLAND A F B TX
78236-9908
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-0123
  • Fax:
Mailing address:
  • Phone: 210-292-6259
  • Fax: 210-292-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number16439
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16439
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: