Provider Demographics
NPI:1114447703
Name:COASTAL DENTAL SERVICES, PLLC
Entity Type:Organization
Organization Name:COASTAL DENTAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-965-5194
Mailing Address - Street 1:5460 BROCKIE ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7737
Mailing Address - Country:US
Mailing Address - Phone:757-965-5194
Mailing Address - Fax:
Practice Address - Street 1:5460 BROCKIE ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-7737
Practice Address - Country:US
Practice Address - Phone:757-965-5194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0443000025261QD0000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental