Healthcare Provider Details

I. General information

NPI: 1104492446
Provider Name (Legal Business Name): COAST DENTAL P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 S WASHINGTON AVE
TITUSVILLE FL
32780-6645
US

IV. Provider business mailing address

5706 BENJAMIN CENTER DR STE 103
TAMPA FL
33634-5262
US

V. Phone/Fax

Practice location:
  • Phone: 321-268-3300
  • Fax: 321-268-3552
Mailing address:
  • Phone: 813-288-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MELODY RIVERA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 813-350-7166