Provider Demographics
NPI:1255710752
Name:WICHITA FALLS ORAL AND FACIAL SURGERY, PLLC
Entity type:Organization
Organization Name:WICHITA FALLS ORAL AND FACIAL SURGERY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:618-402-6622
Mailing Address - Street 1:4447 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 110, PMB 434
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4245
Mailing Address - Country:US
Mailing Address - Phone:800-215-6530
Mailing Address - Fax:
Practice Address - Street 1:2304 MIDWESTERN PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2342
Practice Address - Country:US
Practice Address - Phone:940-696-1544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX248711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty