Provider Demographics
NPI:1710131826
Name:COASTAL JAW SURGERY OF NEW PORT RICHEY, P.A.
Entity Type:Organization
Organization Name:COASTAL JAW SURGERY OF NEW PORT RICHEY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
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 1:2720 PARK DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1020
Practice Address - Country:US
Practice Address - Phone:727-726-8500
Practice Address - Fax:727-725-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN108021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072932900Medicaid
FL072932900Medicaid