Provider Demographics
NPI:1154194249
Name:FULL SMILE OAKWELL FARMS ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:FULL SMILE OAKWELL FARMS ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-353-1055
Mailing Address - Street 1:11330 POTRANCO RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-7282
Mailing Address - Country:US
Mailing Address - Phone:210-828-6787
Mailing Address - Fax:210-824-2652
Practice Address - Street 1:1919 OAKWELL FARMS PKWY STE 240
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-1779
Practice Address - Country:US
Practice Address - Phone:210-828-6787
Practice Address - Fax:210-824-2652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty