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General NPI Number Information
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NPI Number | 1245588169
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Entity Type | Organization
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Legal Business Name | CLEAR LAKE ORAL AND MAXILLOFACIAL SURGEYY, PLLC
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Dates
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Enumeration Date | 08/27/2012
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Last Update Date | 08/27/2012
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Provider Practice Location Address
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Address Line | 17448 HIGHWAY 3 STE 170
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City | WEBSTER
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State | TX
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Zip | 77598-4139
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Country | US
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Telephone | 281-338-7700
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Fax | 281-338-7703
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Provider Business Mailing Address
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Address Line | 17448 HIGHWAY 3 STE 170
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City | WEBSTER
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State | TX
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Zip | 77598-4139
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Country | US
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Telephone | 281-338-7700
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Fax | 281-338-7703
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Authorized Official
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Title or Position | MANAGER/PRESIDENT
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Name | GHOLAM REZA ZAKHIREH
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Credential | DMD
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Telephone | 281-338-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 13577
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License Number State | TX
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