Healthcare Provider Details

I. General information

NPI: 1598069239
Provider Name (Legal Business Name): NORTHWEST FLORIDA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 N 9TH AVE STE 1
PENSACOLA FL
32503-2407
US

IV. Provider business mailing address

4850 N 9TH AVE STE 1
PENSACOLA FL
32503-2407
US

V. Phone/Fax

Practice location:
  • Phone: 850-478-7070
  • Fax: 850-476-2513
Mailing address:
  • Phone: 850-478-7070
  • Fax: 850-476-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN18924
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDN18924
License Number StateFL

VIII. Authorized Official

Name: DR. BRETT T. LAGGAN
Title or Position: ORAL & MAXILLOFACIAL SURGEON
Credential: D.D.S
Phone: 850-478-7070