MEDICARE: GULF COAST DENTAL CENTER

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	MS 1781-77	MS

General Provider Information

NPI Number	:	1700089810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF COAST DENTAL CENTER

Provider Business Mailing Address
First Line	:	3118 15TH ST
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-2708
Country	:	US
Telephone Number	:	228-863-6413
Fax Number	:	228-863-6432

Provider Business Practice Location Address
First Line	:	3118 15TH ST
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-2708
Country	:	US
Telephone Number	:	228-863-6413
Fax Number	:	228-863-6432

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROY L IRONS
Credential	:	D.D.S.
Telephone Number	:	228-863-6413

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	08/22/2020

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