Provider Demographics
NPI:1922288539
Name:PERMIAN BASIN ORAL SURGERY & DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:PERMIAN BASIN ORAL SURGERY & DENTAL IMPLANT CENTER
Other - Org Name:PERMIAN BASIN ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:432-333-6585
Mailing Address - Street 1:8101 DORADO DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8533
Mailing Address - Country:US
Mailing Address - Phone:432-333-6585
Mailing Address - Fax:
Practice Address - Street 1:8101 DORADO DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8533
Practice Address - Country:US
Practice Address - Phone:432-333-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty