Provider Demographics
NPI:1912185703
Name:TRINITY VALLEY ORAL SURGERY & DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:TRINITY VALLEY ORAL SURGERY & DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-689-0704
Mailing Address - Street 1:215 S. FM 548
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126
Mailing Address - Country:US
Mailing Address - Phone:469-689-0704
Mailing Address - Fax:469-689-0709
Practice Address - Street 1:215 S. FM 548
Practice Address - Street 2:SUITE C
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126
Practice Address - Country:US
Practice Address - Phone:469-689-0704
Practice Address - Fax:469-689-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1225036759OtherNPI