Provider Demographics
NPI:1366732141
Name:ATLANTIC COAST ORAL MAXILLOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:ATLANTIC COAST ORAL MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:HERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:360-830-6637
Mailing Address - Street 1:1010 GAR HWY
Mailing Address - Street 2:SUITE #6
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-4566
Mailing Address - Country:US
Mailing Address - Phone:508-676-3041
Mailing Address - Fax:508-678-0222
Practice Address - Street 1:1010 GAR HWY
Practice Address - Street 2:SUITE #6
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4566
Practice Address - Country:US
Practice Address - Phone:508-676-3041
Practice Address - Fax:508-678-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00035886204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty