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General NPI Number Information
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NPI Number | 1346671245
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Entity Type | Organization
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Legal Business Name | BAYLOR COLLEGE OF DENTISTRY
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Dates
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Enumeration Date | 12/03/2013
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 3302 GASTON AVE
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City | DALLAS
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State | TX
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Zip | 75246-2013
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Country | US
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Telephone | 214-828-8213
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Fax |
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Provider Business Mailing Address
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Address Line | 3302 GASTON AVE
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City | DALLAS
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State | TX
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Zip | 75246-2013
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Country | US
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Telephone | 214-828-8213
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF AEGD CLINIC
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Name | DR. CHARLES WAKEFIELD
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Credential | DDS
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Telephone | 214-828-8213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 29122
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License Number State | TX
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