Healthcare Provider Details

I. General information

NPI: 1619243482
Provider Name (Legal Business Name): JOHN CHARLES HORNBERGER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 S US HIGHWAY 75 # 201
DENISON TX
75020
US

IV. Provider business mailing address

4616 S US HIGHWAY 75 # 201
DENISON TX
75020-4582
US

V. Phone/Fax

Practice location:
  • Phone: 903-416-8585
  • Fax: 903-416-8484
Mailing address:
  • Phone: 903-416-8585
  • Fax: 903-416-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9715
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number9715
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number28622
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number28622
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: