Provider Demographics
NPI:1720462849
Name:SOUTHERN DENTAL AT DEERBROOK PLLC
Entity type:Organization
Organization Name:SOUTHERN DENTAL AT DEERBROOK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-794-4588
Mailing Address - Street 1:8000 W. INTERSTATE 10
Mailing Address - Street 2:SUITE 407
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230
Mailing Address - Country:US
Mailing Address - Phone:210-774-4588
Mailing Address - Fax:210-640-5995
Practice Address - Street 1:20131 HWY 59 N
Practice Address - Street 2:SUITE 1238
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:281-445-4237
Practice Address - Fax:281-446-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty