Provider Demographics
NPI:1932204468
Name:EADDY DENTISTRY PA
Entity Type:Organization
Organization Name:EADDY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:EADDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-263-4252
Mailing Address - Street 1:900 RR 620 S
Mailing Address - Street 2:C-200
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734
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:C-200
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734
Practice Address - Country:US
Practice Address - Phone:512-263-4252
Practice Address - Fax:512-263-1568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty