Healthcare Provider Details

I. General information

NPI: 1245588169
Provider Name (Legal Business Name): CLEAR LAKE ORAL AND MAXILLOFACIAL SURGEYY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17448 HIGHWAY 3 STE 170
WEBSTER TX
77598-4139
US

IV. Provider business mailing address

17448 HIGHWAY 3 STE 170
WEBSTER TX
77598-4139
US

V. Phone/Fax

Practice location:
  • Phone: 281-338-7700
  • Fax: 281-338-7703
Mailing address:
  • Phone: 281-338-7700
  • Fax: 281-338-7703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13577
License Number StateTX

VIII. Authorized Official

Name: GHOLAM REZA ZAKHIREH
Title or Position: MANAGER/PRESIDENT
Credential: DMD
Phone: 281-338-7700