Healthcare Provider Details

I. General information

NPI: 1770716813
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL ARTS OF PLANO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 W PARK BLVD
PLANO TX
75093-3839
US

IV. Provider business mailing address

4020 W PARK BLVD
PLANO TX
75093-3839
US

V. Phone/Fax

Practice location:
  • Phone: 972-596-7474
  • Fax:
Mailing address:
  • Phone: 972-596-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number23534
License Number StateTX

VIII. Authorized Official

Name: DR. PRASHANT M REDDY
Title or Position: PRESIDENT
Credential: DDS
Phone: 972-596-7474