Healthcare Provider Details

I. General information

NPI: 1568080497
Provider Name (Legal Business Name): SAN ANTONIO WISDOM TEETH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13535 HAUSMAN PASS #102-A
SAN ANTONIO TX
78249
US

IV. Provider business mailing address

5406 W 11000 N # 226
HIGHLAND UT
84003-8942
US

V. Phone/Fax

Practice location:
  • Phone: 214-307-4039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: RYAN ARNOLD
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-899-5512