MEDICARE: COAST DENTAL P.A.

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	122300000X	Dentist

General Provider Information

NPI Number	:	1104492446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST DENTAL P.A.

Provider Business Mailing Address
First Line	:	5706 BENJAMIN CENTER DR STE 103
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-5262
Country	:	US
Telephone Number	:	813-288-1999
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 S WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6645
Country	:	US
Telephone Number	:	321-268-3300
Fax Number	:	321-268-3552

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MELODY RIVERA
Credential	:
Telephone Number	:	813-350-7166

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/27/2021

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Directions to “COAST DENTAL P.A. ” Practice Location

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