Provider Demographics
NPI:1063987626
Name:RIVER CITY ORAL AND MAXILLOFACIAL SURGERY, PLLC
Entity type:Organization
Organization Name:RIVER CITY ORAL AND MAXILLOFACIAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVERKORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:210-778-0002
Mailing Address - Street 1:PO BOX 1719
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-1719
Mailing Address - Country:US
Mailing Address - Phone:210-778-0002
Mailing Address - Fax:
Practice Address - Street 1:5418 N LOOP 1604 E
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78023
Practice Address - Country:US
Practice Address - Phone:210-778-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery