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General NPI Number Information
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NPI Number | 1548415144
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Entity Type | Organization
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Legal Business Name | EMERALD COAST DENTAL SPA
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Dates
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Enumeration Date | 11/24/2008
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Last Update Date | 01/28/2020
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Provider Practice Location Address
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Address Line | 900 THOMAS DR
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32408-7442
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Country | US
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Telephone | 850-249-9311
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Fax | 850-249-9312
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Provider Business Mailing Address
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Address Line | 900 THOMAS DR
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32408-7442
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Country | US
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Telephone | 850-249-9311
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Fax | 850-249-9312
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Authorized Official
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Title or Position | PRESIDENT/ OWNER
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Name | DR. TARA M GRIFFIN
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Credential | DMD PA
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Telephone | 850-249-9311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 17668
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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