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General NPI Number Information
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NPI Number | 1831557370
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Entity Type | Organization
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Legal Business Name | LAKE JACKSON ORAL AND MAXILLOFACIAL SURGERY, PLLC
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Dates
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Enumeration Date | 01/28/2016
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Last Update Date | 01/28/2016
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Provider Practice Location Address
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Address Line | 103 ABNER JACKSON PKWY
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5163
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Country | US
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Telephone | 979-299-6878
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Fax | 979-299-6166
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Provider Business Mailing Address
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Address Line | 103 ABNER JACKSON PKWY
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5163
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Country | US
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Telephone | 979-299-6878
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Fax | 979-299-6166
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Authorized Official
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Title or Position | PROVIDER
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Name | NATHAN PHILLIPS
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Credential | DDS
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Telephone | 979-299-6878
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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 | 16829
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License Number State | TX
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