Healthcare Provider Details

I. General information

NPI: 1982861225
Provider Name (Legal Business Name): WINSTON MARSHALL EADDY D.M.D., C.A.G.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RR 620 S SUITE C200
LAKEWAY TX
78734-5615
US

IV. Provider business mailing address

900 RR 620 S SUITE C200
LAKEWAY TX
78734-5615
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19252
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: