Provider Demographics
NPI:1427341502
Name:KERRVILLE ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity type:Organization
Organization Name:KERRVILLE ORAL & MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-7366
Mailing Address - Street 1:501 JEFFERSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4561
Mailing Address - Country:US
Mailing Address - Phone:830-895-3494
Mailing Address - Fax:830-896-3390
Practice Address - Street 1:501 JEFFERSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4561
Practice Address - Country:US
Practice Address - Phone:830-895-3494
Practice Address - Fax:830-896-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty