Healthcare Provider Details

I. General information

NPI: 1932204468
Provider Name (Legal Business Name): EADDY DENTISTRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RR 620 S C-200
LAKEWAY TX
78734
US

IV. Provider business mailing address

900 RR 620 S C-200
LAKEWAY TX
78734
US

V. Phone/Fax

Practice location:
  • Phone: 512-263-4252
  • Fax: 512-263-1568
Mailing address:
  • Phone: 512-263-4252
  • Fax: 512-263-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19252
License Number StateTX

VIII. Authorized Official

Name: DR. WINSTON MARSHALL EADDY
Title or Position: PRESIDENT
Credential: DMD
Phone: 512-263-4252