Provider Demographics
NPI:1902112519
Name:CENTER FOR ORAL & RECONSTRUCTIVE SURGERY P A
Entity Type:Organization
Organization Name:CENTER FOR ORAL & RECONSTRUCTIVE SURGERY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMSEY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-359-8100
Mailing Address - Street 1:400 N ALLEN DR
Mailing Address - Street 2:207
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-2555
Mailing Address - Country:US
Mailing Address - Phone:972-359-8100
Mailing Address - Fax:971-359-8107
Practice Address - Street 1:400 N ALLEN DR
Practice Address - Street 2:207
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2555
Practice Address - Country:US
Practice Address - Phone:972-359-8100
Practice Address - Fax:971-359-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty