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700 Olympic Plaza Cir Ste 412 Tyler TX 75701-1952 | |
| (903) 595-5186 | |
| (903) 595-5240 |
| Full Name | |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 700 Olympic Plaza Cir Ste 412, Tyler, Texas |
| Authorized Official Name and Position | Jerri G. Grace (OFFICE MANAGER) |
| Authorized Official Contact | 9035955186 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
700 Olympic Plaza Cir Ste 412 Tyler TX 75701-1952 Ph: (903) 595-5186 | 700 Olympic Plaza Cir Ste 412 Tyler TX 75701-1952 Ph: (903) 595-5186 |
| NPI Number | 1154493922 |
|---|---|
| Provider Enumeration Date | 11/15/2006 |
| Last Update Date | 07/16/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154493922 | NPI | - | NPPES |
| 080858601 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 10456 & 17107 (Texas) | Primary |
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