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General NPI Number Information
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NPI Number | 1255519344
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE PLASTIC SURGERY
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Dates
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Enumeration Date | 01/31/2008
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Last Update Date | 01/31/2008
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Provider Practice Location Address
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Address Line | 900 E SOUTHLAKE BLVD STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6375
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Country | US
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Telephone | 817-442-8900
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Fax | 817-488-2490
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Provider Business Mailing Address
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Address Line | 900 E SOUTHLAKE BLVD STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6375
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Country | US
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Telephone | 817-442-8900
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Fax | 817-488-2490
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Authorized Official
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Title or Position | OWNER
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Name | MARK E MASON
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Credential | MD
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Telephone | 817-442-8900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | J4330
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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