Provider Demographics
NPI:1447673173
Name:CRANIOFACIAL, RECONSTRUCTIVE AND COSMETIC SURGERY ASSOCIATES, LLC
Entity type:Organization
Organization Name:CRANIOFACIAL, RECONSTRUCTIVE AND COSMETIC SURGERY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STONE
Authorized Official - Middle Name:R
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:786-471-4299
Mailing Address - Street 1:1949 ISLA DE PALMA CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6705 SW 57TH AVE STE 510
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3644
Practice Address - Country:US
Practice Address - Phone:786-471-4299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114524204E00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid