Healthcare Provider Details

I. General information

NPI: 1780389882
Provider Name (Legal Business Name): SLATER LYNN BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 07/18/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP JBSA - WILFORD HALL AMBULATORY SURGICAL CENTER
SAN ANTONIO TX
78236
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP JBSA - WILFORD HALL AMBULATORY SURGICAL CENTER
SAN ANTONIO TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7412
  • Fax:
Mailing address:
  • Phone: 210-292-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40715
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: