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General NPI Number Information
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NPI Number | 1356585566
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Entity Type | Organization
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Legal Business Name | PALM COAST DENTAL, LLC
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Dates
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Enumeration Date | 05/01/2009
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Last Update Date | 05/01/2009
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Provider Practice Location Address
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Address Line | 5234 E. HIGHWAY 100 SUITE 103
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City | PALM COAST
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State | FL
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Zip | 32164
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Country | US
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Telephone | 386-263-2936
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Fax |
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Provider Business Mailing Address
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Address Line | 5234 E. HIGHWAY 100 SUITE 103
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City | PALM COAST
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State | FL
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Zip | 32164
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Country | US
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Telephone | 386-263-2936
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Fax | 386-263-2941
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. THAI THANH NONG
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Credential | DMD
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Telephone | 386-237-5917
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN17327
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License Number State | FL
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