=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417170655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORAL & MAXILLOFACIAL NETWORK, P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 S MAIN ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-920-6936
-----------------------------------------------------
Fax | 817-702-1035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 S MAIN ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-920-6936
-----------------------------------------------------
Fax | 817-927-1497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | HOLLY MARIE PORTWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-920-6936
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------