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General NPI Number Information
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NPI Number | 1720462849
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Entity Type | Organization
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Legal Business Name | SOUTHERN DENTAL AT DEERBROOK PLLC
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Dates
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Enumeration Date | 07/17/2015
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Last Update Date | 09/11/2019
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Provider Practice Location Address
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Address Line | 20131 HWY 59 N SUITE 1238
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City | HUMBLE
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State | TX
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Zip | 77338
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Country | US
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Telephone | 281-445-4237
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Fax | 281-446-6942
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Provider Business Mailing Address
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Address Line | 8000 W. INTERSTATE 10 SUITE 407
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City | SAN ANTONIO
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State | TX
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Zip | 78230
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Country | US
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Telephone | 210-774-4588
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Fax | 210-640-5995
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Authorized Official
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Title or Position | CEO/OWNER
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Name | STEVEN WINGFIELD
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Credential | DMD
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Telephone | 210-794-4588
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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 | 30690
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License Number State | TX
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