Provider Demographics
NPI:1447528906
Name:CITRUS ORAL AND MAXILLOFACIAL SURGERY PA
Entity type:Organization
Organization Name:CITRUS ORAL AND MAXILLOFACIAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-795-4994
Mailing Address - Street 1:6129 W CORPORATE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-8732
Mailing Address - Country:US
Mailing Address - Phone:352-795-4994
Mailing Address - Fax:
Practice Address - Street 1:6129 W CORPORATE OAKS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8732
Practice Address - Country:US
Practice Address - Phone:352-795-4994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL88101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty