MEDICARE: COASTAL FAMILY DENTISTRY OF JOHNS ISLAND

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	3539	SC
2	122300000X	Dentist	4360	SC
3	122300000X	Dentist	3298	SC

General Provider Information

NPI Number	:	1699928267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL FAMILY DENTISTRY OF JOHNS ISLAND

Provider Business Mailing Address
First Line	:	2754 MAYBANK HWY
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-559-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	2754 MAYBANK HWY
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-559-5555
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW CARL WATSON
Credential	:	DMD
Telephone Number	:	843-559-5555

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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