Healthcare Provider Details

I. General information

NPI: 1831557370
Provider Name (Legal Business Name): LAKE JACKSON ORAL AND MAXILLOFACIAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ABNER JACKSON PKWY
LAKE JACKSON TX
77566-5163
US

IV. Provider business mailing address

103 ABNER JACKSON PKWY
LAKE JACKSON TX
77566-5163
US

V. Phone/Fax

Practice location:
  • Phone: 979-299-6878
  • Fax: 979-299-6166
Mailing address:
  • Phone: 979-299-6878
  • Fax: 979-299-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16829
License Number StateTX

VIII. Authorized Official

Name: NATHAN PHILLIPS
Title or Position: PROVIDER
Credential: DDS
Phone: 979-299-6878