Provider Demographics
NPI:1568625721
Name:DR STAMBOULIEH ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:DR STAMBOULIEH ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:LEGACY ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:STAMBOULIEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-385-1476
Mailing Address - Street 1:PO BOX 6200
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0228
Mailing Address - Country:US
Mailing Address - Phone:214-385-1476
Mailing Address - Fax:
Practice Address - Street 1:2500 LEGACY DR
Practice Address - Street 2:SUITE 230
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-5983
Practice Address - Country:US
Practice Address - Phone:214-387-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty