Provider Demographics
NPI:1992027676
Name:COASTAL VIRGINIA ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:COASTAL VIRGINIA ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:MAUGERI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-340-0446
Mailing Address - Street 1:3720 HOLLAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2859
Mailing Address - Country:US
Mailing Address - Phone:757-340-0446
Mailing Address - Fax:757-340-2636
Practice Address - Street 1:3720 HOLLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2859
Practice Address - Country:US
Practice Address - Phone:757-340-0446
Practice Address - Fax:757-340-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010059851223S0112X
VA04010060301223S0112X
VA04014113681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty