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General NPI Number Information
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NPI Number | 1366796450
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Entity Type | Organization
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Legal Business Name | CORAL DENTAL AND DENTURE PA
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 04/28/2016
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Provider Practice Location Address
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Address Line | 12711 MCGREGOR BLVD
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City | FORT MYERS
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State | FL
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Zip | 33919-4412
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Country | US
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Telephone | 239-542-3925
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Fax | 239-210-5903
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Provider Business Mailing Address
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Address Line | 12711 MCGREGOR BLVD
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City | FORT MYERS
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State | FL
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Zip | 33919-4412
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Country | US
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Telephone | 239-542-3925
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Fax | 239-210-5903
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUAN CARLOS CASTELLANOS
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Credential | DDS
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Telephone | 239-603-5210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN 19837
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License Number State | FL
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