Provider Demographics
NPI:1700053881
Name:ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Other - Org Name:ORAL & FACIAL SURGEONS OF MID-FL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATTIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-843-1670
Mailing Address - Street 1:1573 W FAIRBANKS AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4679
Mailing Address - Country:US
Mailing Address - Phone:407-644-0224
Mailing Address - Fax:407-644-2827
Practice Address - Street 1:1100 LUCERNE TER
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1050
Practice Address - Country:US
Practice Address - Phone:407-843-1670
Practice Address - Fax:407-841-1827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77201BMedicare PIN