Healthcare Provider Details

I. General information

NPI: 1992027676
Provider Name (Legal Business Name): COASTAL VIRGINIA ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 HOLLAND RD SUITE 100
VIRGINIA BEACH VA
23452-2859
US

IV. Provider business mailing address

3720 HOLLAND RD SUITE 100
VIRGINIA BEACH VA
23452-2859
US

V. Phone/Fax

Practice location:
  • Phone: 757-340-0446
  • Fax: 757-340-2636
Mailing address:
  • Phone: 757-340-0446
  • Fax: 757-340-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401005985
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401006030
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411368
License Number StateVA

VIII. Authorized Official

Name: DR. MICHAEL FRANK MAUGERI JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 757-340-0446