=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386839439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COATOAM PERIODONTAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 W HIGHLAND ST
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-865-6363
-----------------------------------------------------
Fax | 407-865-5957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 W HIGHLAND ST
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-865-6363
-----------------------------------------------------
Fax | 407-865-5957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. SHARON COATOAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-865-6363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN00813
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------