Healthcare Provider Details

I. General information

NPI: 1356741847
Provider Name (Legal Business Name): BAY ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 OHIO AVE
LYNN HAVEN FL
32444-1757
US

IV. Provider business mailing address

725 OHIO AVE
LYNN HAVEN FL
32444-1757
US

V. Phone/Fax

Practice location:
  • Phone: 850-271-8001
  • Fax: 850-277-0390
Mailing address:
  • Phone: 850-271-8001
  • Fax: 850-277-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDN17426
License Number StateFL

VIII. Authorized Official

Name: DR. SCOTT JOSEPH HEITZMANN
Title or Position: ORAL SURGEON/OWNER
Credential: DMD
Phone: 850-271-8001