Provider Demographics
NPI:1730893645
Name:WESTSIDE PLASTIC SURGERY, PLLC
Entity type:Organization
Organization Name:WESTSIDE PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-961-1950
Mailing Address - Street 1:3416 LOVELL AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5718
Mailing Address - Country:US
Mailing Address - Phone:817-961-1950
Mailing Address - Fax:817-887-3105
Practice Address - Street 1:3416 LOVELL AVE STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5718
Practice Address - Country:US
Practice Address - Phone:817-961-1950
Practice Address - Fax:817-887-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty