Provider Demographics
NPI:1982973954
Name:COASTAL ORAL MAXILLOFACIAL SURGERY & IMPLANTS, INC.
Entity Type:Organization
Organization Name:COASTAL ORAL MAXILLOFACIAL SURGERY & IMPLANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:KIELY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-207-0138
Mailing Address - Street 1:5408 DISCOVERY PARK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2893
Mailing Address - Country:US
Mailing Address - Phone:757-208-0138
Mailing Address - Fax:757-206-1981
Practice Address - Street 1:5408 DISCOVERY PARK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2893
Practice Address - Country:US
Practice Address - Phone:757-208-0138
Practice Address - Fax:757-206-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010073031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty