MEDICARE: COAST DENTAL OF SOUTH GEORGIA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1558816991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST DENTAL OF SOUTH GEORGIA PC

Provider Business Mailing Address
First Line	:	4010 W BOY SCOUT BLVD
Second Line	:	SUITE 1100- CREDENTIALING
City	:	TAMPA
State	:	FL
Zip	:	33607-5727
Country	:	US
Telephone Number	:	813-288-1999
Fax Number	:	813-434-2325

Provider Business Practice Location Address
First Line	:	4010 W BOY SCOUT BLVD
Second Line	:	SUITE 1100- CREDENTIALING
City	:	TAMPA
State	:	FL
Zip	:	33607-5727
Country	:	US
Telephone Number	:	813-288-1999
Fax Number	:	813-434-2325

Authorized Official
Title or Position	:	DIRECTOR OF INS. AND CREDENTIALING
Name	:	DARLENE FINNELL
Credential	:
Telephone Number	:	813-288-1999

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/22/2016

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