Healthcare Provider Details

I. General information

NPI: 1558816991
Provider Name (Legal Business Name): COAST DENTAL OF SOUTH GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W BOY SCOUT BLVD SUITE 1100- CREDENTIALING
TAMPA FL
33607-5727
US

IV. Provider business mailing address

4010 W BOY SCOUT BLVD SUITE 1100- CREDENTIALING
TAMPA FL
33607-5727
US

V. Phone/Fax

Practice location:
  • Phone: 813-288-1999
  • Fax: 813-434-2325
Mailing address:
  • Phone: 813-288-1999
  • Fax: 813-434-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DARLENE FINNELL
Title or Position: DIRECTOR OF INS. AND CREDENTIALING
Credential:
Phone: 813-288-1999