Provider Demographics
NPI:1962156117
Name:NORTHWEST TEXAS OMS, PLLC
Entity type:Organization
Organization Name:NORTHWEST TEXAS OMS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-282-5442
Mailing Address - Street 1:3234 64TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-5761
Mailing Address - Country:US
Mailing Address - Phone:806-722-3637
Mailing Address - Fax:806-722-3638
Practice Address - Street 1:3234 64TH ST STE B
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-5761
Practice Address - Country:US
Practice Address - Phone:806-722-3637
Practice Address - Fax:806-722-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental