Healthcare Provider Details

I. General information

NPI: 1487839205
Provider Name (Legal Business Name): COASTAL JAW SURGERY OF NEW PORT RICHEY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6731 MADISON ST
NEW PORT RICHEY FL
34652-1928
US

IV. Provider business mailing address

6731 MADISON ST
NEW PORT RICHEY FL
34652-1928
US

V. Phone/Fax

Practice location:
  • Phone: 727-842-5180
  • Fax: 727-846-0755
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 Number
License Number State

VIII. Authorized Official

Name: DR. MARK W MITCHELL
Title or Position: PRESIDENT
Credential: DDS
Phone: 727-842-5180