Provider Demographics
NPI:1952459307
Name:EAST TEXAS ORAL & MAXILLOFACIAL SURGERY ASSOCIATES INC.
Entity Type:Organization
Organization Name:EAST TEXAS ORAL & MAXILLOFACIAL SURGERY ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-758-3444
Mailing Address - Street 1:3004 H G MOSELEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2948
Mailing Address - Country:US
Mailing Address - Phone:903-758-3444
Mailing Address - Fax:903-758-1967
Practice Address - Street 1:3004 H G MOSELEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2948
Practice Address - Country:US
Practice Address - Phone:903-758-3444
Practice Address - Fax:903-758-1967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111312801Medicaid
TX111312802Medicaid
TX111312802Medicaid