Healthcare Provider Details

I. General information

NPI: 1417618463
Provider Name (Legal Business Name): TREASURE COAST ORAL & MAXILLOFACIAL SURG & DENTAL IMPLANT SURG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5376
US

IV. Provider business mailing address

1265 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5376
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-4798
  • Fax: 772-337-2004
Mailing address:
  • Phone: 772-337-4798
  • Fax: 772-337-2004

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: STEPHANIE KAUFFMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 772-337-4798