Healthcare Provider Details

I. General information

NPI: 1649091513
Provider Name (Legal Business Name): CODY JOEL PEWARCHUK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

IV. Provider business mailing address

13135 SHORELINE DR
SAN ANTONIO TX
78254-6325
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-3700
  • Fax:
Mailing address:
  • Phone: 210-793-2608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberETN1084
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00206141
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: