MEDICARE: BRAZOS VALLEY OMS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	10460	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	10404	TX
3	122300000X	Dentist	10404	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	813315	OTHER	TN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1194931303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZOS VALLEY OMS PLLC

Provider Business Mailing Address
First Line	:	1505 EMERALD PLAZA
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-1501
Country	:	US
Telephone Number	:	979-764-7101
Fax Number	:	979-764-7115

Provider Business Practice Location Address
First Line	:	1505 EMERALD PLAZA
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-1501
Country	:	US
Telephone Number	:	979-764-7101
Fax Number	:	979-764-7115

Authorized Official
Title or Position	:	OWNER/SURGEON
Name	:	JAMES BRYAN GARRETT
Credential	:	DDS, MD
Telephone Number	:	979-764-7101

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	01/02/2020

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Directions to “BRAZOS VALLEY OMS PLLC ” Practice Location

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