Provider Demographics
NPI:1437475019
Name:JEQUINTO, DAVE GOLDWYN (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVE GOLDWYN
Middle Name:
Last Name:JEQUINTO
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 1:12055 VANCE JACKSON RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-6058
Mailing Address - Country:US
Mailing Address - Phone:210-568-9800
Mailing Address - Fax:
Practice Address - Street 1:12055 VANCE JACKSON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-6058
Practice Address - Country:US
Practice Address - Phone:210-568-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA591731223G0001X
TX294061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice