MEDICARE: ELEVATED ORAL SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1114700747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATED ORAL SURGERY

Provider Business Mailing Address
First Line	:	1106 WITTE RD STE 300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-2164
Country	:	US
Telephone Number	:	281-940-5315
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 WITTE RD STE 300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-2164
Country	:	US
Telephone Number	:	281-940-5315
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	SUSANA C PORRAS
Credential	:	DMD
Telephone Number	:	281-940-5315

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	08/22/2023

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Directions to “ELEVATED ORAL SURGERY ” Practice Location

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