MEDICARE: FRESH COAST DENTAL 2 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1700744398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH COAST DENTAL 2 LLC

Provider Business Mailing Address
First Line	:	4010 S CHURCH DR
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-5608
Country	:	US
Telephone Number	:	551-216-7433
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 S CHURCH DR
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-5608
Country	:	US
Telephone Number	:	551-216-7433
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/PARTNER
Name	:	DR. TUSHAR CHIMANBHAI THUMMAR
Credential	:	DMD
Telephone Number	:	551-216-7433

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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