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General NPI Number Information
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NPI Number | 1164125456
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Entity Type | Organization
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Legal Business Name | FOSSIL DENTAL
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Dates
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Enumeration Date | 03/24/2023
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Last Update Date | 03/24/2023
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Provider Practice Location Address
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Address Line | 8142 SHIN OAK DR STE 100
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City | LIVE OAK
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State | TX
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Zip | 78233-2775
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Country | US
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Telephone | 210-888-5832
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Fax |
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Provider Business Mailing Address
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Address Line | 8142 SHIN OAK DR STE 100
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City | LIVE OAK
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State | TX
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Zip | 78233-2775
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Country | US
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Telephone | 210-888-5832
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. WALTER D THAMES
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Credential | DDS, MS
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Telephone | 210-888-5832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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