Provider Demographics
NPI:1043023088
Name:CLEBURNE ORAL SURGERY PA
Entity type:Organization
Organization Name:CLEBURNE ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KOSTOHRYZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:817-357-8999
Mailing Address - Street 1:2010 W KATHERINE P RAINES RD STE 700
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7462
Mailing Address - Country:US
Mailing Address - Phone:817-357-8999
Mailing Address - Fax:
Practice Address - Street 1:2010 W KATHERINE P RAINES RD STE 700
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7462
Practice Address - Country:US
Practice Address - Phone:817-357-8999
Practice Address - Fax:817-357-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty