Provider Demographics
NPI:1760497291
Name:RICHARDSON ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:RICHARDSON ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAVELKA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-231-6661
Mailing Address - Street 1:400 S COTTONWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5708
Mailing Address - Country:US
Mailing Address - Phone:972-231-6661
Mailing Address - Fax:972-231-3161
Practice Address - Street 1:400 S COTTONWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5708
Practice Address - Country:US
Practice Address - Phone:972-231-6661
Practice Address - Fax:972-231-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty