Provider Demographics
NPI:1366533747
Name:I SDG, PLLC
Entity type:Organization
Organization Name:I SDG, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:GUILLORY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-227-0101
Mailing Address - Street 1:930 S ALAMO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-3419
Mailing Address - Country:US
Mailing Address - Phone:210-227-0101
Mailing Address - Fax:210-212-6125
Practice Address - Street 1:930 S ALAMO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-3419
Practice Address - Country:US
Practice Address - Phone:210-227-0101
Practice Address - Fax:210-212-6125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16271 TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX695689OtherUNITED CONCORDIA INS.
TX0905986-02Medicaid
TXB16271OtherDELTA DENTAL TEXAS CHIP