Provider Demographics
NPI: | 1700188372 |
---|---|
Name: | CENTER FOR FACIAL ORAL & IMPLANT SURGERY PA |
Entity Type: | Organization |
Organization Name: | CENTER FOR FACIAL ORAL & IMPLANT SURGERY PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GREGORY |
Authorized Official - Middle Name: | P |
Authorized Official - Last Name: | HATZIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS, MD |
Authorized Official - Phone: | 903-315-3813 |
Mailing Address - Street 1: | 705 E MARSHALL AVE |
Mailing Address - Street 2: | 4003 |
Mailing Address - City: | LONGVIEW |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75601 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-315-3810 |
Mailing Address - Fax: | 903-315-1937 |
Practice Address - Street 1: | 705 E MARSHALL AVE |
Practice Address - Street 2: | 4003 |
Practice Address - City: | LONGVIEW |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75601-5573 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-315-3810 |
Practice Address - Fax: | 903-315-1937 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-12-02 |
Last Update Date: | 2011-05-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Single Specialty |