Healthcare Provider Details

I. General information

NPI: 1730625740
Provider Name (Legal Business Name): FACIAL HEAD & NECK SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 COIT RD STE A
PLANO TX
75075-3774
US

IV. Provider business mailing address

1202 S ADAMS ST
FORT WORTH TX
76104-4428
US

V. Phone/Fax

Practice location:
  • Phone: 618-541-2864
  • Fax: 817-500-5032
Mailing address:
  • Phone: 503-866-3780
  • Fax: 817-500-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SIAVASH EFTEKHARI
Title or Position: SOLE MBR
Credential: MD, DMD
Phone: 503-866-3780