Provider Demographics
NPI:1225321565
Name:LAKE TRAVIS ORAL & MAXILLOFACIAL SURGERY, PLLC.
Entity Type:Organization
Organization Name:LAKE TRAVIS ORAL & MAXILLOFACIAL SURGERY, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-261-6900
Mailing Address - Street 1:1921 LOHMANS CROSSING
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5282
Mailing Address - Country:US
Mailing Address - Phone:512-261-6900
Mailing Address - Fax:512-532-0303
Practice Address - Street 1:1921 LOHMANS CROSSING
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5282
Practice Address - Country:US
Practice Address - Phone:512-261-6900
Practice Address - Fax:512-532-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21279204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty