Healthcare Provider Details

I. General information

NPI: 1811733769
Provider Name (Legal Business Name): CHISHOLM TRAIL ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 HARRIS PKWY STE 140
FORT WORTH TX
76132-4218
US

IV. Provider business mailing address

4137 TRAILS END DR APT 2018
FORT WORTH TX
76116-0785
US

V. Phone/Fax

Practice location:
  • Phone: 903-530-7382
  • Fax:
Mailing address:
  • Phone: 903-530-7382
  • Fax:

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: CRAIG HARRISON
Title or Position: OWNER / PROVIDER
Credential:
Phone: 817-484-4778