Healthcare Provider Details

I. General information

NPI: 1740545144
Provider Name (Legal Business Name): COASTAL PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 POND PARK RD STE 308 COASTAL PLASTIC SURGERY LLC
HINGHAM MA
02043-4354
US

IV. Provider business mailing address

2 POND PARK RD STE 308 COASTAL PLASTIC SURGERY LLC
HINGHAM MA
02043-4354
US

V. Phone/Fax

Practice location:
  • Phone: 781-740-7840
  • Fax: 781-740-9840
Mailing address:
  • Phone: 781-740-7840
  • Fax: 781-740-9840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number219506
License Number StateMA

VIII. Authorized Official

Name: DR. DAX GUENTHER
Title or Position: SOLE MBR
Credential: MD
Phone: 781-740-7840