Provider Demographics
NPI:1104214451
Name:COASTAL DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:COASTAL DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-931-2196
Mailing Address - Street 1:118 ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-4721
Mailing Address - Country:US
Mailing Address - Phone:508-994-2255
Mailing Address - Fax:
Practice Address - Street 1:118 ALDEN RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-4721
Practice Address - Country:US
Practice Address - Phone:508-994-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty