Provider Demographics
NPI:1467694208
Name:THE CENTER FOR ORAL, FACIAL, AND IMPLANT SURGERY PA
Entity Type:Organization
Organization Name:THE CENTER FOR ORAL, FACIAL, AND IMPLANT SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DERAE
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:OMS
Authorized Official - Phone:817-477-0922
Mailing Address - Street 1:2310 HIGHWAY 157 N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8844
Mailing Address - Country:US
Mailing Address - Phone:817-477-0922
Mailing Address - Fax:817-477-0910
Practice Address - Street 1:2310 HIGHWAY 157 N
Practice Address - Street 2:SUITE 103
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8844
Practice Address - Country:US
Practice Address - Phone:817-477-0922
Practice Address - Fax:817-477-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2168OtherMEDICARE ID
TXV08126Medicare UPIN