Provider Demographics
NPI:1750425963
Name:CHILDERS, DARRELL (DDS)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15303 HUEBNER RD
Mailing Address - Street 2:BLDG 17
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-0959
Mailing Address - Country:US
Mailing Address - Phone:210-696-2563
Mailing Address - Fax:210-764-7226
Practice Address - Street 1:15303 HUEBNER RD
Practice Address - Street 2:BLDG 17
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-0959
Practice Address - Country:US
Practice Address - Phone:210-696-2563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics