Provider Demographics
NPI:1629592787
Name:DRISDALE, JOHN KING III (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KING
Last Name:DRISDALE
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 S CONGRESS AVE APT 1123
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-1762
Mailing Address - Country:US
Mailing Address - Phone:512-468-5071
Mailing Address - Fax:
Practice Address - Street 1:1337 THORPE LN
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7113
Practice Address - Country:US
Practice Address - Phone:512-396-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice