Provider Demographics
NPI:1497750806
Name:PEAVY, DAN C (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:C
Last Name:PEAVY
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W OLMOS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1988
Mailing Address - Country:US
Mailing Address - Phone:210-826-3201
Mailing Address - Fax:
Practice Address - Street 1:100 W OLMOS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1988
Practice Address - Country:US
Practice Address - Phone:210-826-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics