Provider Demographics
NPI:1982964839
Name:WINDCREST PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:WINDCREST PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYLVESTER
Authorized Official - Middle Name:C
Authorized Official - Last Name:AWAGU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-657-4641
Mailing Address - Street 1:5500 WALZEM RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-2103
Mailing Address - Country:US
Mailing Address - Phone:210-657-4641
Mailing Address - Fax:210-655-4012
Practice Address - Street 1:5500 WALZEM RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-2103
Practice Address - Country:US
Practice Address - Phone:210-657-4641
Practice Address - Fax:210-655-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty