Provider Demographics
NPI:1316086465
Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-358-2997
Mailing Address - Street 1:23051 KINGWOOD PLACE DR
Mailing Address - Street 2:BLDG A, STE 100
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339
Mailing Address - Country:US
Mailing Address - Phone:281-358-2997
Mailing Address - Fax:281-358-5632
Practice Address - Street 1:23051 KINGWOOD PLACE DR
Practice Address - Street 2:BLDG A, STE 100
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:281-358-2997
Practice Address - Fax:281-358-5632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16440204E00000X
TX14816204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14816Medicare UPIN
16440Medicare UPIN