Provider Demographics
NPI:1699155507
Name:IMPLANTS AND ORAL SURGERY, PC
Entity type:Organization
Organization Name:IMPLANTS AND ORAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERONTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-292-3605
Mailing Address - Street 1:7217 HAWKINS VIEW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3928
Mailing Address - Country:US
Mailing Address - Phone:817-292-3605
Mailing Address - Fax:817-292-1743
Practice Address - Street 1:7217 HAWKINS VIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3928
Practice Address - Country:US
Practice Address - Phone:817-292-3605
Practice Address - Fax:817-292-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211071223S0112X
TX231541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty