Provider Demographics
NPI:1417021247
Name:GENECOV PLASTIC SURGERY GROUP
Entity Type:Organization
Organization Name:GENECOV PLASTIC SURGERY GROUP
Other - Org Name:CRANIOFACIAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:GENECOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-566-6555
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:SUITE C717
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-6555
Mailing Address - Fax:972-566-6017
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE B312
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-6555
Practice Address - Fax:972-566-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology