Basic Information
| Provider Information | |||||||||
| NPI: | 1700178555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TEXAS MAXILLOFACIAL SURGERY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10175 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155046880 | ||||||||
| FaxNumber: | 9155998579 | ||||||||
| Practice Location | |||||||||
| Address1: | 10175 GATEWAY BLVD W | ||||||||
| Address2: | SUITE304 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155046880 | ||||||||
| FaxNumber: | 9155998579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | VERNON | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2106309909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 25153 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.