Provider Demographics
NPI:1346671245
Name:BAYLOR COLLEGE OF DENTISTRY
Entity Type:Organization
Organization Name:BAYLOR COLLEGE OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AEGD CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-828-8213
Mailing Address - Street 1:3302 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2013
Mailing Address - Country:US
Mailing Address - Phone:214-828-8213
Mailing Address - Fax:
Practice Address - Street 1:3302 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2013
Practice Address - Country:US
Practice Address - Phone:214-828-8213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty