Provider Demographics
NPI:1033720065
Name:WATERFORD ORAL SURGERY
Entity Type:Organization
Organization Name:WATERFORD ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-773-4444
Mailing Address - Street 1:5246 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3513
Mailing Address - Country:US
Mailing Address - Phone:254-773-4444
Mailing Address - Fax:254-773-4449
Practice Address - Street 1:5246 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-3513
Practice Address - Country:US
Practice Address - Phone:254-773-4444
Practice Address - Fax:254-773-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35686Medicaid