Provider Demographics
NPI:1700178555
Name:WEST TEXAS MAXILLOFACIAL SURGERY PA
Entity type:Organization
Organization Name:WEST TEXAS MAXILLOFACIAL SURGERY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:P
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-630-9909
Mailing Address - Street 1:10175 GATEWAY BLVD W
Mailing Address - Street 2:SUITE 304
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7618
Mailing Address - Country:US
Mailing Address - Phone:915-504-6880
Mailing Address - Fax:915-599-8579
Practice Address - Street 1:10175 GATEWAY BLVD W
Practice Address - Street 2:SUITE304
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7618
Practice Address - Country:US
Practice Address - Phone:915-504-6880
Practice Address - Fax:915-599-8579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST TEXAS MAXILLOFACIAL SURGERY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-12
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25153204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty