Provider Demographics
NPI:1811733769
Name:CHISHOLM TRAIL ORAL SURGERY PLLC
Entity type:Organization
Organization Name:CHISHOLM TRAIL ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-484-4778
Mailing Address - Street 1:4137 TRAILS END DR APT 2018
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0785
Mailing Address - Country:US
Mailing Address - Phone:903-530-7382
Mailing Address - Fax:
Practice Address - Street 1:7040 HARRIS PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4218
Practice Address - Country:US
Practice Address - Phone:903-530-7382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty