1588021950 NPI number — HERITAGE ORAL AND FACIAL SURGERY, PLLC

Table of content: (NPI 1588021950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588021950 NPI number — HERITAGE ORAL AND FACIAL SURGERY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE ORAL AND FACIAL SURGERY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588021950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1237 COUNTY ROAD 197
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76538-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-300-8804
Provider Business Mailing Address Fax Number:
254-350-2868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1237 COUNTY ROAD 197
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76538-1207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-300-8804
Provider Business Practice Location Address Fax Number:
254-350-2868
Provider Enumeration Date:
01/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOWLES
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
DYLAN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
910-922-9644

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  21840 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com