MEDICARE: TEXAS ORAL AND FACIAL 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	18986	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88D134	OTHER	TX	BC/BS PROVIDER
2	164989	OTHER	TX	DBP
3	51107	OTHER	TX	ASSURANCE
4	509663782	OTHER	TX	UCCI
5	51107	OTHER	TX	DHA

General Provider Information

NPI Number	:	1477540052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS ORAL AND FACIAL SURGERY

Provider Business Mailing Address
First Line	:	810 S MASON RD
Second Line	:	SUITE 301
City	:	KATY
State	:	TX
Zip	:	77450-3895
Country	:	US
Telephone Number	:	281-395-1200
Fax Number	:	281-395-1201

Provider Business Practice Location Address
First Line	:	810 S MASON RD
Second Line	:	SUITE 301
City	:	KATY
State	:	TX
Zip	:	77450-3895
Country	:	US
Telephone Number	:	281-395-1200
Fax Number	:	281-395-1201

Authorized Official
Title or Position	:	DR
Name	:	RAYMOND L WIGGINS
Credential	:	D.D.S., M.D.
Telephone Number	:	281-395-1200

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	03/05/2013

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Directions to “TEXAS ORAL AND FACIAL SURGERY ” Practice Location

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