Healthcare Provider Details

I. General information

NPI: 1447673173
Provider Name (Legal Business Name): CRANIOFACIAL, RECONSTRUCTIVE AND COSMETIC SURGERY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6705 SW 57TH AVE STE 510
SOUTH MIAMI FL
33143-3644
US

IV. Provider business mailing address

1949 ISLA DE PALMA CIR
NAPLES FL
34119-3403
US

V. Phone/Fax

Practice location:
  • Phone: 786-471-4299
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME114524
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME114524
License Number StateFL

VIII. Authorized Official

Name: DR. STONE R THAYER
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 786-471-4299