Provider Demographics
NPI:1063781086
Name:HARBOR VIEW ORAL AND FACIAL SURGERY LLC
Entity type:Organization
Organization Name:HARBOR VIEW ORAL AND FACIAL SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROSETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:228-867-0121
Mailing Address - Street 1:1301 25TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:228-867-0121
Mailing Address - Fax:228-867-0252
Practice Address - Street 1:1301 25TH AVENUE
Practice Address - Street 2:SUITE 3
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-867-0121
Practice Address - Fax:228-867-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3358051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03520709Medicaid