Provider Demographics
NPI:1477216620
Name:OBSIDIAN MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:OBSIDIAN MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-231-8568
Mailing Address - Street 1:3117 COLLEGE PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4192
Mailing Address - Country:US
Mailing Address - Phone:936-231-8568
Mailing Address - Fax:
Practice Address - Street 1:3117 COLLEGE PARK DR STE 150
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-4192
Practice Address - Country:US
Practice Address - Phone:936-231-8568
Practice Address - Fax:936-447-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty