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General NPI Number Information
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NPI Number | 1295863207
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Entity Type | Organization
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Legal Business Name | ANGELO ORAL & MAXILLOFACIAL SURGERY, P. A.
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3012 GREEN MEADOW DR
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City | SAN ANGELO
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State | TX
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Zip | 76904-6974
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Country | US
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Telephone | 325-944-3565
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Fax |
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Provider Business Mailing Address
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Address Line | 3012 GREEN MEADOW DR
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City | SAN ANGELO
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State | TX
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Zip | 76904-6974
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Country | US
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Telephone | 325-944-3565
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GRADY W. BRYAN
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Credential | DDS, MD
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Telephone | 325-944-3565
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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 | 14472
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License Number State | TX
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