Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 PARK DR
CLEARWATER FL
33763-1020
US

IV. Provider business mailing address

6731 MADISON ST
NEW PORT RICHEY FL
34652-1928
US

V. Phone/Fax

Practice location:
  • Phone: 727-726-8500
  • Fax: 727-725-9716
Mailing address:
  • Phone: 727-842-5180
  • Fax: 727-846-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN10802
License Number StateFL

VIII. Authorized Official

Name: DR. MARK WAYNE MITCHELL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 727-842-5180