Healthcare Provider Details

I. General information

NPI: 1700178555
Provider Name (Legal Business Name): WEST TEXAS MAXILLOFACIAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 GATEWAY BLVD W SUITE304
EL PASO TX
79925-7618
US

IV. Provider business mailing address

10175 GATEWAY BLVD W SUITE 304
EL PASO TX
79925-7618
US

V. Phone/Fax

Practice location:
  • Phone: 915-504-6880
  • Fax: 915-599-8579
Mailing address:
  • Phone: 915-504-6880
  • Fax: 915-599-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number25153
License Number StateTX

VIII. Authorized Official

Name: VERNON P BURKE
Title or Position: DIRECTOR
Credential: DMD
Phone: 210-630-9909