MEDICARE: COASTAL JAW SURGERY OF NEW PORT RICHEY, P.A.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN10802	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710131826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL JAW SURGERY OF NEW PORT RICHEY, P.A.

Provider Business Mailing Address
First Line	:	6731 MADISON ST
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-1928
Country	:	US
Telephone Number	:	727-842-5180
Fax Number	:	727-846-0755

Provider Business Practice Location Address
First Line	:	2720 PARK DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33763-1020
Country	:	US
Telephone Number	:	727-726-8500
Fax Number	:	727-725-9716

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK WAYNE MITCHELL
Credential	:	D.D.S.
Telephone Number	:	727-842-5180

Provider Enumeration Date	:	11/17/2008
Last Update Date	:	11/17/2008

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