Provider Demographics
NPI:1871515726
Name:PESSOA, WINSTON GEORGE
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:GEORGE
Last Name:PESSOA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 NORMAN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-5631
Mailing Address - Country:US
Mailing Address - Phone:334-262-2092
Mailing Address - Fax:
Practice Address - Street 1:1710 NORMAN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36104-5631
Practice Address - Country:US
Practice Address - Phone:334-262-2092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL#05979Medicare UPIN