=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285317990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST DENTAL CARE OF BILOXI PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2023
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232A EISENHOWER DR
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-388-9551
-----------------------------------------------------
Fax | 228-388-9552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232A EISENHOWER DR
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-388-9551
-----------------------------------------------------
Fax | 228-832-0186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. ROBERT L SUTTON III
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 228-832-3231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------