MEDICARE: CRANIOFACIAL, RECONSTRUCTIVE AND COSMETIC SURGERY ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	ME114524	FL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	ME114524	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

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

Provider Business Mailing Address
First Line	:	1949 ISLA DE PALMA CIR
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34119-3403
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6705 SW 57TH AVE STE 510
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-3644
Country	:	US
Telephone Number	:	786-471-4299
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STONE R THAYER
Credential	:	DMD, MD
Telephone Number	:	786-471-4299

Provider Enumeration Date	:	01/31/2014
Last Update Date	:	01/24/2015

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