Healthcare Provider Details

I. General information

NPI: 1861807646
Provider Name (Legal Business Name): FACIAL & ORAL SURGICAL SOLUTIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TREEMONT DR
ORANGE CITY FL
32763-7978
US

IV. Provider business mailing address

400 TREEMONT DR
ORANGE CITY FL
32763-7978
US

V. Phone/Fax

Practice location:
  • Phone: 386-837-1236
  • Fax: 386-960-7636
Mailing address:
  • Phone: 386-837-1236
  • Fax: 386-960-7636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 20469
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 13469
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 17491
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberME 114524
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME 114524
License Number StateFL

VIII. Authorized Official

Name: STONE RANGARAJAN THAYER
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 386-837-1236