MEDICARE: EADO FAMILY DENTAL - NORTHSIDE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1023831310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EADO FAMILY DENTAL - NORTHSIDE PLLC

Provider Business Mailing Address
First Line	:	2607 CLAY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77003-4516
Country	:	US
Telephone Number	:	917-331-3281
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 PINEMONT DR STE I
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-1323
Country	:	US
Telephone Number	:	917-331-3281
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN WILSON MA
Credential	:
Telephone Number	:	917-331-3281

Provider Enumeration Date	:	11/05/2024
Last Update Date	:	11/05/2024

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