Provider Demographics
NPI:1700188372
Name:CENTER FOR FACIAL ORAL & IMPLANT SURGERY PA
Entity type:Organization
Organization Name:CENTER FOR FACIAL ORAL & IMPLANT SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:HATZIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:903-315-3813
Mailing Address - Street 1:705 E MARSHALL AVE
Mailing Address - Street 2:4003
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601
Mailing Address - Country:US
Mailing Address - Phone:903-315-3810
Mailing Address - Fax:903-315-1937
Practice Address - Street 1:705 E MARSHALL AVE
Practice Address - Street 2:4003
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5573
Practice Address - Country:US
Practice Address - Phone:903-315-3810
Practice Address - Fax:903-315-1937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty