MEDICARE: COASTAL ENDONTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3662	SC

General Provider Information

NPI Number	:	1093996282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL ENDONTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4776
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585-8776
Country	:	US
Telephone Number	:	843-235-9780
Fax Number	:	843-235-8444

Provider Business Practice Location Address
First Line	:	277B WILLBROOK BOULEVARD
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585-8776
Country	:	US
Telephone Number	:	843-235-9780
Fax Number	:	843-235-8444

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. RUSSELL S EDDY
Credential	:	DMD
Telephone Number	:	843-235-9780

Provider Enumeration Date	:	11/16/2007
Last Update Date	:	11/16/2007

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