Healthcare Provider Details

I. General information

NPI: 1154194249
Provider Name (Legal Business Name): FULL SMILE OAKWELL FARMS ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 OAKWELL FARMS PKWY STE 240
SAN ANTONIO TX
78218-1779
US

IV. Provider business mailing address

11330 POTRANCO RD STE 105
SAN ANTONIO TX
78253-7282
US

V. Phone/Fax

Practice location:
  • Phone: 210-828-6787
  • Fax: 210-824-2652
Mailing address:
  • Phone: 210-828-6787
  • Fax: 210-824-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WILLIAMS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 806-353-1055