Healthcare Provider Details

I. General information

NPI: 1679595946
Provider Name (Legal Business Name): DREW WAYNE FALLIS SR. D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BERGQUIST DR STE 1 ATTN: DARLON JACKSON, CREDENTIALS MANAGER
LACKLAND A F B TX
78236-9908
US

IV. Provider business mailing address

8610 MANTANO RDG
HELOTES TX
78023-4705
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7395
  • Fax: 210-292-7964
Mailing address:
  • Phone: 210-372-0777
  • Fax: 210-292-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4870
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: