Provider Demographics
NPI:1366831372
Name:PWD DENTISTRY MANAGEMENT LLC
Entity Type:Organization
Organization Name:PWD DENTISTRY MANAGEMENT LLC
Other - Org Name:PINEY WOODS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VIGNOS
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:713-876-4560
Mailing Address - Street 1:2804 LAKE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-5626
Mailing Address - Country:US
Mailing Address - Phone:713-876-4560
Mailing Address - Fax:
Practice Address - Street 1:2804 LAKE RD STE 5
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-5626
Practice Address - Country:US
Practice Address - Phone:936-439-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PWD DENTISTRY MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty