Healthcare Provider Details

I. General information

NPI: 1942410246
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGEONS OF MID-FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LUCERNE TER STE 100
ORLANDO FL
32806-1050
US

IV. Provider business mailing address

195 BRIAR CLIFF DR STE 101
LONGWOOD FL
32779-4443
US

V. Phone/Fax

Practice location:
  • Phone: 407-843-1670
  • Fax: 407-841-1827
Mailing address:
  • Phone: 407-774-3399
  • Fax: 407-774-4322

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: JEFFREY L BEATTIE
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 407-774-3399