Healthcare Provider Details

I. General information

NPI: 1689821621
Provider Name (Legal Business Name): STANISLAUS DYDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 05/22/2022
Certification Date: 05/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 FLOYD CURL DR
SAN ANTONIO TX
78229-3923
US

IV. Provider business mailing address

122 ROY SMITH ST APT 2404
SAN ANTONIO TX
78215-1371
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-3700
  • Fax:
Mailing address:
  • Phone: 517-614-2154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2316
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019872
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number38263
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: