Healthcare Provider Details

I. General information

NPI: 1386691343
Provider Name (Legal Business Name): GULF COAST ORAL & FACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 MEDICAL PARK DR SUITE A
BILOXI MS
39532-2131
US

IV. Provider business mailing address

1760 MEDICAL PARK DR SUITE A
BILOXI MS
39532-2131
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-5925
  • Fax: 228-388-8153
Mailing address:
  • Phone: 228-388-5925
  • Fax: 228-388-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT T WATTS, JR
Title or Position: PHYSICAIN/OWNER
Credential: D.M.D.
Phone: 228-388-5925