Provider Demographics
NPI:1639553746
Name:SOUTHERN DENTAL AT BAYBROOK PLLC
Entity Type:Organization
Organization Name:SOUTHERN DENTAL AT BAYBROOK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-906-1769
Mailing Address - Street 1:1235 W BAY AREA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-3832
Mailing Address - Country:US
Mailing Address - Phone:281-332-6780
Mailing Address - Fax:
Practice Address - Street 1:1235 W BAY AREA BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-3832
Practice Address - Country:US
Practice Address - Phone:281-332-6780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX306901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty