Provider Demographics
NPI:1407341191
Name:COPPELL ORAL AND FACIAL SURGERY, PLLC
Entity Type:Organization
Organization Name:COPPELL ORAL AND FACIAL SURGERY, PLLC
Other - Org Name:COPPELL ORAL AND FACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:N
Authorized Official - Last Name:TIKHONOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:206-719-8396
Mailing Address - Street 1:220 S DENTON TAP RD STE 101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5098
Mailing Address - Country:US
Mailing Address - Phone:972-366-0065
Mailing Address - Fax:972-744-3305
Practice Address - Street 1:220 S DENTON TAP RD STE 101
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5098
Practice Address - Country:US
Practice Address - Phone:206-719-8396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX324481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty