NPIMap

Organization Active NPI

Wichita Falls Oral and Facial Surgery, PLLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Wichita Falls, TX
National Provider Identifier
1255710752
Registry record updated May 29, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
24871 Issued in TX
Legal business name
WICHITA FALLS ORAL AND FACIAL SURGERY, PLLC
Practice address
2304 Midwestern Pkwy
Suite 102
Wichita Falls, TX 76308-2342
Phone
(940) 696-1544
NPI assigned
May 29, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Clark Allen Petersen Jr.
Title
Operations Director
Phone
(618) 402-6622

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X 24871 TX Primary

Addresses

Primary practice location

2304 Midwestern Pkwy
Suite 102
Wichita Falls, TX 76308-2342

Mailing address

4447 N Central Expy
Suite 110, PMB 434
Dallas, TX 75205-4245
Phone (800) 215-6530

Other names 1

  • Texoma Facial and Oral Surgery Doing business as

National Provider Directory

National Provider Directory

Locations

2304 Midwestern Pkwy
Ste 102
Wichita Falls, TX 76308
Phone (940) 696-1544

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432857600000",
    "number": "1255710752",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4447 N CENTRAL EXPY",
            "address_2": "SUITE 110, PMB 434",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752054245",
            "telephone_number": "800-215-6530"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2304 MIDWESTERN PKWY",
            "address_2": "SUITE 102",
            "city": "WICHITA FALLS",
            "state": "TX",
            "postal_code": "763082342",
            "telephone_number": "940-696-1544"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WICHITA FALLS ORAL AND FACIAL SURGERY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-29",
        "last_updated": "2015-05-29",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "CLARK",
        "authorized_official_middle_name": "ALLEN",
        "authorized_official_title_or_position": "OPERATIONS DIRECTOR",
        "authorized_official_telephone_number": "618-402-6622",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "TX",
            "license": "24871",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Texoma Facial and Oral Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wichita Falls, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.