Provider Demographics
NPI:1518351790
Name:ROSWELL ORAL & FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:ROSWELL ORAL & FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:575-522-8800
Mailing Address - Street 1:2103 TELSHOR CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8245
Mailing Address - Country:US
Mailing Address - Phone:575-522-8800
Mailing Address - Fax:575-521-4448
Practice Address - Street 1:207 N UNION AVE
Practice Address - Street 2:STE E
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3068
Practice Address - Country:US
Practice Address - Phone:575-623-5711
Practice Address - Fax:575-622-8922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD30681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty