Healthcare Provider Details

I. General information

NPI: 1417961376
Provider Name (Legal Business Name): GULF COAST DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15503 OAK LN # 300B
GULFPORT MS
39503-2697
US

IV. Provider business mailing address

15503 OAK LN STE 300B
GULFPORT MS
39503-2697
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-3231
  • Fax: 228-832-0186
Mailing address:
  • Phone: 228-832-3231
  • Fax: 228-832-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER M COVINGTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 228-832-3231