Provider Demographics
NPI:1588021950
Name:HERITAGE ORAL AND FACIAL SURGERY, PLLC
Entity Type:Organization
Organization Name:HERITAGE ORAL AND FACIAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DYLAN
Authorized Official - Last Name:BOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-922-9644
Mailing Address - Street 1:1237 COUNTY ROAD 197
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76538-1207
Mailing Address - Country:US
Mailing Address - Phone:254-300-8804
Mailing Address - Fax:254-350-2868
Practice Address - Street 1:1237 COUNTY ROAD 197
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:TX
Practice Address - Zip Code:76538-1207
Practice Address - Country:US
Practice Address - Phone:254-300-8804
Practice Address - Fax:254-350-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty