Healthcare Provider Details

I. General information

NPI: 1053762823
Provider Name (Legal Business Name): KATY CENTER FOR ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23922 CINCO VILLAGE CENTER BLVD SUITE 111
KATY TX
77494-6619
US

IV. Provider business mailing address

23922 CINCO VILLAGE CENTER BLVD SUITE 111
KATY TX
77494-6619
US

V. Phone/Fax

Practice location:
  • Phone: 281-392-1130
  • Fax:
Mailing address:
  • Phone: 281-392-1130
  • 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: TANIA IMPASTATO
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 281-392-1130