Provider Demographics
NPI:1013392463
Name:RICHARDSON ORAL SURGERY AND IMPLANT CENTER PLLC
Entity Type:Organization
Organization Name:RICHARDSON ORAL SURGERY AND IMPLANT CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMPBELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:972-231-6661
Mailing Address - Street 1:1070 W CAMPBELL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2941
Mailing Address - Country:US
Mailing Address - Phone:972-231-6661
Mailing Address - Fax:972-231-3161
Practice Address - Street 1:1070 W CAMPBELL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2941
Practice Address - Country:US
Practice Address - Phone:972-231-6661
Practice Address - Fax:972-231-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty