Provider Demographics
NPI:1225115470
Name:SOUTHEASTERN ORAL & MAXILLOFACIAL SURGEONS PC
Entity Type:Organization
Organization Name:SOUTHEASTERN ORAL & MAXILLOFACIAL SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-588-0200
Mailing Address - Street 1:951 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-588-0200
Mailing Address - Fax:508-583-6156
Practice Address - Street 1:951 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-588-0200
Practice Address - Fax:508-583-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX20040Medicaid
MAX20040Medicaid
MAX20040Medicare ID - Type Unspecified