Provider Demographics
NPI:1730369299
Name:CENTRAL TX ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:CENTRAL TX ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-699-9500
Mailing Address - Street 1:2030 HEIGHTS DR STE 3
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2185
Mailing Address - Country:US
Mailing Address - Phone:254-699-9500
Mailing Address - Fax:254-699-2796
Practice Address - Street 1:2030 HEIGHTS DR STE 3
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2185
Practice Address - Country:US
Practice Address - Phone:254-699-9500
Practice Address - Fax:254-699-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110929003Medicaid
TX110929001Medicaid
TX110929001Medicaid
TX00940TMedicare PIN