Provider Demographics
NPI:1003216250
Name:ORAL AND FACIAL SURGERY INSTITUTE PA
Entity Type:Organization
Organization Name:ORAL AND FACIAL SURGERY INSTITUTE PA
Other - Org Name:ORAL AND FACIAL SURGERY INSTITUTE OF HOUSTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-790-6477
Mailing Address - Street 1:4724 SWEETWATER BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3150
Mailing Address - Country:US
Mailing Address - Phone:281-491-4545
Mailing Address - Fax:281-491-7134
Practice Address - Street 1:4724 SWEETWATER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-491-4545
Practice Address - Fax:281-491-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty