MEDICARE: COASTAL ORAL & MAXILLOFACIAL SURGEONS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	017511	NJ

General Provider Information

NPI Number	:	1174738363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL ORAL & MAXILLOFACIAL SURGEONS, PA

Provider Business Mailing Address
First Line	:	199 NEW RD
Second Line	:	CENTRAL SQUARE SUITE 32
City	:	LINWOOD
State	:	NJ
Zip	:	08221-2025
Country	:	US
Telephone Number	:	609-927-9090
Fax Number	:	609-927-9091

Provider Business Practice Location Address
First Line	:	199 NEW RD
Second Line	:	CENTRAL SQUARE SUITE 32
City	:	LINWOOD
State	:	NJ
Zip	:	08221-2025
Country	:	US
Telephone Number	:	609-927-9090
Fax Number	:	609-927-9091

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT S FIEDLER
Credential	:	DMD
Telephone Number	:	609-927-9090

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	07/09/2010

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