Provider Demographics
NPI:1679595946
Name:FALLIS, DREW WAYNE SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:WAYNE
Last Name:FALLIS
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8610 MANTANO RDG
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4705
Mailing Address - Country:US
Mailing Address - Phone:210-372-0777
Mailing Address - Fax:210-292-5935
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:ATTN: DARLON JACKSON, CREDENTIALS MANAGER
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7395
Practice Address - Fax:210-292-7964
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK48701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics