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General NPI Number Information
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NPI Number | 1710131826
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Entity Type | Organization
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Legal Business Name | COASTAL JAW SURGERY OF NEW PORT RICHEY, P.A.
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Dates
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Enumeration Date | 11/17/2008
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Last Update Date | 11/17/2008
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Provider Practice Location Address
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Address Line | 2720 PARK DR
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City | CLEARWATER
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State | FL
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Zip | 33763-1020
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Country | US
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Telephone | 727-726-8500
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Fax | 727-725-9716
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Provider Business Mailing Address
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Address Line | 6731 MADISON ST
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-1928
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Country | US
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Telephone | 727-842-5180
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Fax | 727-846-0755
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK WAYNE MITCHELL
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Credential | D.D.S.
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Telephone | 727-842-5180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN10802
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License Number State | FL
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