Provider Demographics
NPI:1194197632
Name:GULF COAST DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:GULF COAST DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-344-4747
Mailing Address - Street 1:259 E HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4996
Mailing Address - Country:US
Mailing Address - Phone:352-344-4747
Mailing Address - Fax:352-344-1942
Practice Address - Street 1:259 E HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4996
Practice Address - Country:US
Practice Address - Phone:352-344-4747
Practice Address - Fax:352-344-1942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18310261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental