| Southern Surgical Arts | |
|
2550 Elkton Trl Tyler TX 75703-0594 | |
| (903) 534-1414 | |
| (903) 534-1415 |
| Full Name | Southern Surgical Arts |
|---|---|
| Speciality | Dentist |
| Location | 2550 Elkton Trl, Tyler, Texas |
| Authorized Official Name and Position | Charles G Stone (OWNER/OFFICER) |
| Authorized Official Contact | 9035341414 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Surgical Arts 2550 Elkton Trl Tyler TX 75703-0594 Ph: (903) 534-1414 | Southern Surgical Arts 2550 Elkton Trl Tyler TX 75703-0594 Ph: (903) 534-1414 |
| NPI Number | 1912258740 |
|---|---|
| Provider Enumeration Date | 09/19/2012 |
| Last Update Date | 12/26/2013 |
| Medicare PECOS PAC ID | 9234382284 |
|---|---|
| Medicare Enrollment ID | O20121227000177 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912258740 | NPI | - | NPPES |
| 1206989-09 | Medicaid | TX | |
| 1305898-08 | Medicaid | TX | |
| 2032740-06 | Medicaid | TX | |
| 3126690-03 | Medicaid | TX | |
| 1206989-08 | Medicaid | TX | |
| 1896953-05 | Medicaid | TX | |
| 2032740-07 | Medicaid | TX | |
| 1305898-09 | Medicaid | TX | |
| 1896953-06 | Medicaid | TX | |
| 3099020-01 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Primary |
| Provider Name | Brian H Stone |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1265650071 PECOS PAC ID: 0345319984 Enrollment ID: I20080521000823 |
| Provider Name | Charles G Stone |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1841219342 PECOS PAC ID: 8628124245 Enrollment ID: I20090923000813 |
| Provider Name | Wade Ryan Barker |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1740612084 PECOS PAC ID: 0244453272 Enrollment ID: I20191127001024 |
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