Healthcare Provider Details

I. General information

NPI: 1770134876
Provider Name (Legal Business Name): RED RIVER ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 HIGHWAY 75 SUITE 201
DENISON TX
75020
US

IV. Provider business mailing address

4616 US HWY 75 # 201
DENISON TX
75020-4582
US

V. Phone/Fax

Practice location:
  • Phone: 713-899-5218
  • Fax:
Mailing address:
  • Phone: 903-416-8585
  • Fax: 903-416-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN CHARLES HORNBERGER
Title or Position: MEMBER
Credential: DDS
Phone: 713-899-5218