Provider Demographics
NPI:1942410246
Name:ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Other - Org Name:ORAL AND FACIAL SURGEONS OF MID-FL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEATTIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-774-3399
Mailing Address - Street 1:195 BRIAR CLIFF DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4443
Mailing Address - Country:US
Mailing Address - Phone:407-774-3399
Mailing Address - Fax:407-774-4322
Practice Address - Street 1:1100 LUCERNE TER STE 100
Practice Address - Street 2:
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:2007-05-23
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77201Medicare PIN