Provider Demographics
NPI:1487038428
Name:CELEBRACES WALZEM PLLC
Entity Type:Organization
Organization Name:CELEBRACES WALZEM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, CAGS
Authorized Official - Phone:210-683-6353
Mailing Address - Street 1:5201 WALZEM RD
Mailing Address - Street 2:
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78218-2122
Mailing Address - Country:US
Mailing Address - Phone:210-683-6353
Mailing Address - Fax:210-451-0000
Practice Address - Street 1:5201 WALZEM RD
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78218-2122
Practice Address - Country:US
Practice Address - Phone:210-683-6353
Practice Address - Fax:210-451-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty