Provider Demographics
NPI:1982861225
Name:EADDY, WINSTON MARSHALL (DMD, CAGS)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:MARSHALL
Last Name:EADDY
Suffix:
Gender:M
Credentials:DMD, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RR 620 S
Mailing Address - Street 2:SUITE C200
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5615
Mailing Address - Country:US
Mailing Address - Phone:512-263-4252
Mailing Address - Fax:512-263-1568
Practice Address - Street 1:900 RR 620 S
Practice Address - Street 2:SUITE C200
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5615
Practice Address - Country:US
Practice Address - Phone:512-263-4252
Practice Address - Fax:512-263-1568
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice