MEDICARE: INTERCOASTAL DENTAL PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1205563004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCOASTAL DENTAL PLLC

Provider Business Mailing Address
First Line	:	104 SANTA BARBARA WAY
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4319
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11940 US 1 STE 245
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33408-2832
Country	:	US
Telephone Number	:	626-264-0182
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALEXANDRE EIAN GAETA
Credential	:	DDS
Telephone Number	:	626-264-0182

Provider Enumeration Date	:	08/02/2022
Last Update Date	:	08/02/2022

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