Provider Demographics
NPI:1114700747
Name:ELEVATED ORAL SURGERY
Entity Type:Organization
Organization Name:ELEVATED ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PORRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-940-5315
Mailing Address - Street 1:1106 WITTE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-2164
Mailing Address - Country:US
Mailing Address - Phone:281-940-5315
Mailing Address - Fax:
Practice Address - Street 1:1106 WITTE RD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-2164
Practice Address - Country:US
Practice Address - Phone:281-940-5315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery