Provider Demographics
NPI:1790778314
Name:AESTHETIC ORAL & FACIAL SURGICAL CENTER OF THE SOUTHWEST, PC
Entity Type:Organization
Organization Name:AESTHETIC ORAL & FACIAL SURGICAL CENTER OF THE SOUTHWEST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:STARCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-431-9566
Mailing Address - Street 1:1850 KELLER PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3706
Mailing Address - Country:US
Mailing Address - Phone:817-431-9566
Mailing Address - Fax:817-337-8687
Practice Address - Street 1:1850 KELLER PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3706
Practice Address - Country:US
Practice Address - Phone:817-431-9566
Practice Address - Fax:817-337-8687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17519261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery