Provider Demographics
NPI:1558514588
Name:SOUTHWEST ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:SOUTHWEST ORAL & MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-644-8500
Mailing Address - Street 1:1001 BUCKINGHAM RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5850
Mailing Address - Country:US
Mailing Address - Phone:972-644-8500
Mailing Address - Fax:972-644-0104
Practice Address - Street 1:1001 BUCKINGHAM RD
Practice Address - Street 2:SUITE 106
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-5850
Practice Address - Country:US
Practice Address - Phone:972-644-8500
Practice Address - Fax:972-644-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10599OtherTEXAS LICENSE NUMBER