Healthcare Provider Details

I. General information

NPI: 1366716490
Provider Name (Legal Business Name): EMERALD COAST DENTAL SLEEP MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
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: 850-249-9331
  • Fax: 850-249-9332
Mailing address:
  • Phone: 850-249-9331
  • Fax: 850-249-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDN17668
License Number StateFL

VIII. Authorized Official

Name: DR. TARA M GRIFFIN
Title or Position: CEO
Credential: DMD
Phone: 850-249-9311