Healthcare Provider Details

I. General information

NPI: 1700053881
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LUCERNE TER SUITE 100
ORLANDO FL
32806-1050
US

IV. Provider business mailing address

1573 W FAIRBANKS AVE SUITE 300
WINTER PARK FL
32789-4679
US

V. Phone/Fax

Practice location:
  • Phone: 407-843-1670
  • Fax: 407-841-1827
Mailing address:
  • Phone: 407-644-0224
  • Fax: 407-644-2827

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. JEFFREY BEATTIE
Title or Position: OWNER
Credential: DMD
Phone: 407-843-1670