Provider Demographics
NPI:1487832010
Name:ADVANCED FACIAL PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:ADVANCED FACIAL PLASTIC SURGERY CENTER
Other - Org Name:ADVANCED
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:AMOS
Authorized Official - Last Name:BASSICHIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:972-774-1777
Mailing Address - Street 1:14755 PRESTON ROAD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254
Mailing Address - Country:US
Mailing Address - Phone:972-774-1777
Mailing Address - Fax:972-774-0066
Practice Address - Street 1:14755 PRESTON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-6815
Practice Address - Country:US
Practice Address - Phone:972-774-1777
Practice Address - Fax:972-774-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2643174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00787VMedicare PIN