Healthcare Provider Details

I. General information

NPI: 1093693590
Provider Name (Legal Business Name): COASTAL PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GANDY DANCER
RICHMOND HILL GA
31324-8897
US

IV. Provider business mailing address

1101 GANDY DANCER
RICHMOND HILL GA
31324-8897
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-5437
  • Fax:
Mailing address:
  • Phone: 912-756-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TERRI H HUBBARD
Title or Position: OWNER
Credential: DMD
Phone: 912-756-5437