Provider Demographics
NPI:1396237624
Name:PALESTINE ORAL FACIAL SURGERY GROUP PLLC
Entity type:Organization
Organization Name:PALESTINE ORAL FACIAL SURGERY GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:STONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-520-6448
Mailing Address - Street 1:1721 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-6921
Mailing Address - Country:US
Mailing Address - Phone:903-723-5111
Mailing Address - Fax:903-723-0328
Practice Address - Street 1:1721 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6921
Practice Address - Country:US
Practice Address - Phone:903-723-5111
Practice Address - Fax:903-723-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty