Provider Demographics
NPI:1881807592
Name:FOSSUM DENTAL GROUP
Entity type:Organization
Organization Name:FOSSUM DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:RCHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSSUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-778-3900
Mailing Address - Street 1:2534 BLUE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7924
Mailing Address - Country:US
Mailing Address - Phone:254-778-3900
Mailing Address - Fax:
Practice Address - Street 1:201 W FM 2410 RD
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1709
Practice Address - Country:US
Practice Address - Phone:254-699-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX223041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty