Organization
THE CENTER FOR ORAL, FACIAL, AND IMPLANT SURGERY PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL DERAE SHEPPARD OMS (PRESIDENT)
(817) 477-0922
Entity
Organization
Contact information
Practice address
2310 HIGHWAY 157 N, SUITE 103, MANSFIELD, TX 76063-8844
(817) 477-0922
(817) 477-0910
Mailing address
2310 HIGHWAY 157 N, SUITE 103, MANSFIELD, TX 76063-8844
(817) 477-0922
(817) 477-0910
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
21182
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8F2168
MEDICARE ID
TX
Enumeration date
03/25/2009
Last updated
03/25/2009
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