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NPI Code Detail

MEDICARE: SOUTH COAST DENTAL GROUP LLC

MEDICARE: SOUTH COAST DENTAL GROUP LLC
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
1122300000XDentistD9399OR
21223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1790096402
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH COAST DENTAL GROUP LLC
Provider Business Mailing Address
First Line : 295 S 10TH ST
Second Line :
City : COOS BAY
State : OR
Zip : 97420-4623
Country : US
Telephone Number : 541-269-5353
Fax Number : 541-266-0933
Provider Business Practice Location Address
First Line : 295 S 10TH ST
Second Line :
City : COOS BAY
State : OR
Zip : 97420-4623
Country : US
Telephone Number : 541-269-5353
Fax Number : 541-266-0933
Authorized Official
Title or Position : BILLING & CLAIMS MANAGER
Name : MR. NICHOLAS I HORN
Credential :
Telephone Number : 541-269-5353
Provider Enumeration Date : 06/28/2010
Last Update Date : 02/23/2024

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Directions to “SOUTH COAST DENTAL GROUP LLC ” Practice Location

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