Provider Demographics
NPI:1972771053
Name:MANSFIELD ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:MANSFIELD ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:JOYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-453-4404
Mailing Address - Street 1:1705 FOUNTAINVIEW DR #103
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:817-453-4404
Mailing Address - Fax:817-453-4416
Practice Address - Street 1:1705 FOUNTAINVIEW DR #103
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-453-4404
Practice Address - Fax:817-453-4416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL97101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176821001Medicaid