Provider Demographics
NPI:1194767707
Name:NEW IMAGE MAXILLOFACIAL LLC
Entity type:Organization
Organization Name:NEW IMAGE MAXILLOFACIAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCHMID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-725-5377
Mailing Address - Street 1:1325 S PINE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3189
Mailing Address - Country:US
Mailing Address - Phone:321-725-5377
Mailing Address - Fax:321-951-3393
Practice Address - Street 1:1325 S PINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3189
Practice Address - Country:US
Practice Address - Phone:321-725-5377
Practice Address - Fax:321-951-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN74131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFK119YMedicare PIN
FLHT321AMedicare PIN
FL86404XMedicare PIN