MEDICARE: HIGHLAND PARK ORAL AND MAXILLOFACIAL 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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

General Provider Information

NPI Number	:	1891673240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLAND PARK ORAL AND MAXILLOFACIAL SURGERY PLLC

Provider Business Mailing Address
First Line	:	550 RESERVE ST STE 330
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-1599
Country	:	US
Telephone Number	:	817-226-6790
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 KNOX ST STE 301
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-5593
Country	:	US
Telephone Number	:	817-717-3071
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID KOSTOHRYZ JR.
Credential	:	DDS, MD
Telephone Number	:	817-731-2789

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	08/25/2025

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