Provider Demographics
NPI:1316360373
Name:ABILEN ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:ABILEN ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KETHLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:325-437-3100
Mailing Address - Street 1:4 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5289
Mailing Address - Country:US
Mailing Address - Phone:325-437-3100
Mailing Address - Fax:325-437-3199
Practice Address - Street 1:4 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5289
Practice Address - Country:US
Practice Address - Phone:325-437-3100
Practice Address - Fax:325-437-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136335007Medicaid