MEDICARE: CHISHOLM TRAIL ORAL SURGERY PLLC

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)

General Provider Information

NPI Number	:	1811733769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHISHOLM TRAIL ORAL SURGERY PLLC

Provider Business Mailing Address
First Line	:	4137 TRAILS END DR APT 2018
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0785
Country	:	US
Telephone Number	:	903-530-7382
Fax Number	:

Provider Business Practice Location Address
First Line	:	7040 HARRIS PKWY STE 140
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4218
Country	:	US
Telephone Number	:	903-530-7382
Fax Number	:

Authorized Official
Title or Position	:	OWNER / PROVIDER
Name	:	CRAIG HARRISON
Credential	:
Telephone Number	:	817-484-4778

Provider Enumeration Date	:	07/01/2024
Last Update Date	:	10/29/2024

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