Healthcare Provider Details

I. General information

NPI: 1417170655
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL NETWORK, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 817-920-6936
  • Fax: 817-702-1035
Mailing address:
  • Phone: 817-920-6936
  • Fax: 817-927-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: HOLLY MARIE PORTWOOD
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 817-920-6936