Provider Demographics
NPI:1902410699
Name:BIGWAY FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:BIGWAY FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AYODELE
Authorized Official - Middle Name:OLUROPO
Authorized Official - Last Name:IFARAJIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:240-528-1096
Mailing Address - Street 1:11930 W US HIGHWAY 90 STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-9613
Mailing Address - Country:US
Mailing Address - Phone:210-858-5570
Mailing Address - Fax:210-858-9494
Practice Address - Street 1:11930 U.S . HWY. 90, WEST
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78252
Practice Address - Country:US
Practice Address - Phone:240-528-1096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX384599215Medicaid