Provider Demographics
NPI:1912258740
Name:STONE ORAL FACIAL SURGERY GROUP PLLC
Entity Type:Organization
Organization Name:STONE ORAL FACIAL SURGERY GROUP PLLC
Other - Org Name:SOUTHERN SURGICAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:STONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-534-1414
Mailing Address - Street 1:2550 ELKTON TRL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0594
Mailing Address - Country:US
Mailing Address - Phone:903-534-1414
Mailing Address - Fax:903-534-1415
Practice Address - Street 1:2550 ELKTON TRL
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0594
Practice Address - Country:US
Practice Address - Phone:903-534-1414
Practice Address - Fax:903-534-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1206989-09Medicaid
TX1305898-08Medicaid
TX2032740-06Medicaid
TX3126690-03Medicaid
TX1206989-08Medicaid
TX1896953-05Medicaid
TX2032740-07Medicaid
TX1305898-09Medicaid
TX1896953-06Medicaid
TX3099020-01Medicaid
TX3126690-03Medicaid
TX1206989-09Medicaid
TX1305898-08Medicaid
TX1305898-09Medicaid
TX1896953-05Medicaid