Healthcare Provider Details

I. General information

NPI: 1255710752
Provider Name (Legal Business Name): WICHITA FALLS ORAL AND FACIAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 MIDWESTERN PKWY SUITE 102
WICHITA FALLS TX
76308-2342
US

IV. Provider business mailing address

4447 N CENTRAL EXPY SUITE 110, PMB 434
DALLAS TX
75205-4245
US

V. Phone/Fax

Practice location:
  • Phone: 940-696-1544
  • Fax:
Mailing address:
  • Phone: 800-215-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number24871
License Number StateTX

VIII. Authorized Official

Name: MR. CLARK ALLEN PETERSEN JR.
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 618-402-6622