Provider Demographics
NPI:1598069239
Name:NORTHWEST FLORIDA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:NORTHWEST FLORIDA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:T
Authorized Official - Last Name:LAGGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-478-7070
Mailing Address - Street 1:4850 N 9TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2407
Mailing Address - Country:US
Mailing Address - Phone:850-478-7070
Mailing Address - Fax:850-476-2513
Practice Address - Street 1:4850 N 9TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2407
Practice Address - Country:US
Practice Address - Phone:850-478-7070
Practice Address - Fax:850-476-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN189241223S0112X, 261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073210900Medicaid
FL076708500Medicaid
FLT78763Medicare UPIN