Provider Demographics
NPI:1336826593
Name:ELITE ORAL SURGERY CONROE PLLC
Entity Type:Organization
Organization Name:ELITE ORAL SURGERY CONROE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER/HR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRANZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-256-8400
Mailing Address - Street 1:15260 TX 105 W
Mailing Address - Street 2:SUITE 154
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356
Mailing Address - Country:US
Mailing Address - Phone:832-416-1341
Mailing Address - Fax:832-529-1461
Practice Address - Street 1:15260 TX 105 W
Practice Address - Street 2:SUITE 154
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356
Practice Address - Country:US
Practice Address - Phone:832-416-1341
Practice Address - Fax:832-529-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty