Provider Demographics
NPI:1649834680
Name:LIVE OAK ORAL SURGERY OF TEXAS PLLC
Entity type:Organization
Organization Name:LIVE OAK ORAL SURGERY OF TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GLIDDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-699-3131
Mailing Address - Street 1:2708 SOUTHWEST PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-3735
Mailing Address - Country:US
Mailing Address - Phone:580-699-3131
Mailing Address - Fax:580-699-3151
Practice Address - Street 1:2708 SOUTHWEST PKWY STE 130
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-3735
Practice Address - Country:US
Practice Address - Phone:580-699-3131
Practice Address - Fax:580-699-3151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty