Provider Demographics
NPI:1003114547
Name:GULFCOAST DENTAL CENTER
Entity Type:Organization
Organization Name:GULFCOAST DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:IRONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:228-863-6413
Mailing Address - Street 1:3118 15TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2708
Mailing Address - Country:US
Mailing Address - Phone:228-863-6413
Mailing Address - Fax:
Practice Address - Street 1:3118 15TH STREET
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-863-6413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1781-771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty