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General NPI Number Information
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NPI Number | 1821433145
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Entity Type | Organization
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Legal Business Name | COASTAL KIDS PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 04/30/2013
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Last Update Date | 05/04/2016
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Provider Practice Location Address
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Address Line | 18947 JOHN J WILLIAMS HWY SUITE 309
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City | REHOBOTH BEACH
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State | DE
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Zip | 19971-4474
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Country | US
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Telephone | 610-733-4300
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Fax |
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Provider Business Mailing Address
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Address Line | 18947 JOHN J WILLIAMS HWY SUITE 309
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City | REHOBOTH BEACH
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State | DE
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Zip | 19971-4474
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Country | US
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Telephone | 610-733-4300
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. JESSICA S DI CERBO
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Credential | D.M.D.
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Telephone | 610-733-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | G1-0001296
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License Number State | DE
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