Healthcare Provider Details

I. General information

NPI: 1962888149
Provider Name (Legal Business Name): KOVACH ORAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4969 E INTERSTATE 20 SERVICE RD N
WILLOW PARK TX
76087-3220
US

IV. Provider business mailing address

4969 E INTERSTATE 20 SERVICE RD N
WILLOW PARK TX
76087-3220
US

V. Phone/Fax

Practice location:
  • Phone: 817-441-5000
  • Fax: 817-441-5003
Mailing address:
  • Phone: 817-441-5000
  • Fax: 817-441-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number23925
License Number StateTX

VIII. Authorized Official

Name: DR. TODD A KOVACH
Title or Position: MANAGING MEMBER
Credential: DDS, MD
Phone: 817-441-5000