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General NPI Number Information
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NPI Number | 1336495274
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Entity Type | Organization
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Legal Business Name | FIRST COAST DENTAL GROUP, PA
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Dates
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Enumeration Date | 07/30/2012
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Last Update Date | 07/30/2012
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Provider Practice Location Address
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Address Line | 802 3RD ST
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City | NEPTUNE BEACH
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State | FL
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Zip | 32266-5018
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Country | US
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Telephone | 904-247-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 802 3RD ST
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City | NEPTUNE BEACH
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State | FL
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Zip | 32266-5018
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Country | US
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Telephone | 904-247-0111
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. ANTHONY RAMIRO CORRAL
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Credential | DMD
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Telephone | 904-247-0111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN17063
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License Number State | FL
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