Provider Demographics
NPI:1164932356
Name:TAMPA BAY MAXILLOFACIAL SURGERY, PLLC
Entity Type:Organization
Organization Name:TAMPA BAY MAXILLOFACIAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-894-1442
Mailing Address - Street 1:4021 LAS PALMAS WAY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-4531
Mailing Address - Country:US
Mailing Address - Phone:727-424-5540
Mailing Address - Fax:
Practice Address - Street 1:2140 16TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-3924
Practice Address - Country:US
Practice Address - Phone:727-894-1442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty