Provider Demographics
NPI:1487839205
Name:COASTAL JAW SURGERY OF NEW PORT RICHEY PA
Entity Type:Organization
Organization Name:COASTAL JAW SURGERY OF NEW PORT RICHEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-842-5180
Mailing Address - Street 1:6731 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-1928
Mailing Address - Country:US
Mailing Address - Phone:727-842-5180
Mailing Address - Fax:727-846-0755
Practice Address - Street 1:6731 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-1928
Practice Address - Country:US
Practice Address - Phone:727-842-5180
Practice Address - Fax:727-846-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty