MEDICARE: ORAL SURGERY OF TEXAS 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	261QD0000X	Dental Clinic/Center
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1912592692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORAL SURGERY OF TEXAS PLLC

Provider Business Mailing Address
First Line	:	505 E HUNTLAND DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78752-3717
Country	:	US
Telephone Number	:	512-276-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 W 34TH ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78705-2008
Country	:	US
Telephone Number	:	512-206-2929
Fax Number	:

Authorized Official
Title or Position	:	ONBOARDING SPECIALIST
Name	:	MONICA PERKINS
Credential	:
Telephone Number	:	770-692-1000

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	03/04/2021

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