Provider Demographics
NPI:1386691343
Name:GULF COAST ORAL & FACIAL SURGERY, P.A.
Entity type:Organization
Organization Name:GULF COAST ORAL & FACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAIN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:WATTS, JR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-388-5925
Mailing Address - Street 1:1760 MEDICAL PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2131
Mailing Address - Country:US
Mailing Address - Phone:228-388-5925
Mailing Address - Fax:228-388-8153
Practice Address - Street 1:1760 MEDICAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2131
Practice Address - Country:US
Practice Address - Phone:228-388-5925
Practice Address - Fax:228-388-8153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS852815OtherUNITED CONCORDIA