Provider Demographics
NPI:1831356542
Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOTSIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-296-9562
Mailing Address - Street 1:4185 TECHNOLOGY FOREST BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-2006
Mailing Address - Country:US
Mailing Address - Phone:281-296-9562
Mailing Address - Fax:281-296-9774
Practice Address - Street 1:4185 TECHNOLOGY FOREST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-2006
Practice Address - Country:US
Practice Address - Phone:281-296-9562
Practice Address - Fax:281-296-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty