Healthcare Provider Details

I. General information

NPI: 1174738363
Provider Name (Legal Business Name): COASTAL ORAL & MAXILLOFACIAL SURGEONS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 NEW RD CENTRAL SQUARE SUITE 32
LINWOOD NJ
08221-2025
US

IV. Provider business mailing address

199 NEW RD CENTRAL SQUARE SUITE 32
LINWOOD NJ
08221-2025
US

V. Phone/Fax

Practice location:
  • Phone: 609-927-9090
  • Fax: 609-927-9091
Mailing address:
  • Phone: 609-927-9090
  • Fax: 609-927-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number017511
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT S FIEDLER
Title or Position: PRESIDENT
Credential: DMD
Phone: 609-927-9090