Provider Demographics
NPI:1447886619
Name:EAST TEXAS OMFS TRAUMA CONSULTANTS, PLLC
Entity type:Organization
Organization Name:EAST TEXAS OMFS TRAUMA CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-1414
Mailing Address - Street 1:2550 ELKTON TRL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0594
Mailing Address - Country:US
Mailing Address - Phone:903-534-1414
Mailing Address - Fax:903-534-1415
Practice Address - Street 1:2550 ELKTON TRL
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0594
Practice Address - Country:US
Practice Address - Phone:903-534-1414
Practice Address - Fax:903-534-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty