Provider Demographics
NPI:1326923939
Name:HIGHLAND PARK MSO LLC
Entity type:Organization
Organization Name:HIGHLAND PARK MSO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-739-5685
Mailing Address - Street 1:550 RESERVE ST STE 330
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1599
Mailing Address - Country:US
Mailing Address - Phone:817-226-6790
Mailing Address - Fax:
Practice Address - Street 1:3001 KNOX ST STE 301
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-5593
Practice Address - Country:US
Practice Address - Phone:214-824-8960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty