Provider Demographics
NPI:1831324540
Name:CAPITAL ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:CAPITAL ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-989-7855
Mailing Address - Street 1:15901 CENTRAL COMMERCE DR STE 601
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-2047
Mailing Address - Country:US
Mailing Address - Phone:512-989-7855
Mailing Address - Fax:512-989-7859
Practice Address - Street 1:15901 CENTRAL COMMERCE DR STE 601
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2047
Practice Address - Country:US
Practice Address - Phone:512-989-7855
Practice Address - Fax:512-989-7859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty