Provider Demographics
NPI:1700307220
Name:SUNCOAST ORAL SURGERY & PERIODONTICS
Entity type:Organization
Organization Name:SUNCOAST ORAL SURGERY & PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-832-0028
Mailing Address - Street 1:200 TAMIAMI TRL N
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-1914
Mailing Address - Country:US
Mailing Address - Phone:941-484-4001
Mailing Address - Fax:
Practice Address - Street 1:200 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-1914
Practice Address - Country:US
Practice Address - Phone:941-484-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDALLION PERIODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty