Healthcare Provider Details

I. General information

NPI: 1548415144
Provider Name (Legal Business Name): EMERALD COAST DENTAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 THOMAS DR
PANAMA CITY BEACH FL
32408-7442
US

IV. Provider business mailing address

900 THOMAS DR
PANAMA CITY BEACH FL
32408-7442
US

V. Phone/Fax

Practice location:
  • Phone: 850-249-9311
  • Fax: 850-249-9312
Mailing address:
  • Phone: 850-249-9311
  • Fax: 850-249-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number17668
License Number StateFL

VIII. Authorized Official

Name: DR. TARA M GRIFFIN
Title or Position: PRESIDENT/ OWNER
Credential: DMD PA
Phone: 850-249-9311