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General NPI Number Information
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NPI Number | 1063756401
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Entity Type | Organization
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Legal Business Name | BANDON COASTAL DENTAL, LLC
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Dates
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Enumeration Date | 11/26/2012
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Last Update Date | 11/26/2012
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Provider Practice Location Address
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Address Line | 1097 BALTIMORE AVE
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City | BANDON
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State | OR
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Zip | 97411
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Country | US
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Telephone | 541-329-0550
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 429 1097 BALTIMORE AVE
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City | BANDON
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State | OR
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Zip | 97411
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Country | US
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Telephone | 541-329-0550
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Fax | 541-329-0309
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAUL MORRIS PANTLEO
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Credential | D.D.S.
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Telephone | 541-329-0550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | D9802
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License Number State | OR
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