Provider Demographics
NPI:1619977493
Name:EDGIN, WENDELL ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:ALAN
Last Name:EDGIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4499 MEDICAL DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3735
Mailing Address - Country:US
Mailing Address - Phone:210-614-3916
Mailing Address - Fax:210-614-3918
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:SUITE 190
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-614-3916
Practice Address - Fax:210-614-3918
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141763601Medicaid
TX141763604Medicaid
U86452Medicare UPIN
TX141763601Medicaid