Provider Demographics
NPI:1316402878
Name:CORAL DENTAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:CORAL DENTAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRATHIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADUSUMILLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:954-642-1013
Mailing Address - Street 1:11332 WILES RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2114
Mailing Address - Country:US
Mailing Address - Phone:954-642-1013
Mailing Address - Fax:
Practice Address - Street 1:11332 WILES RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2114
Practice Address - Country:US
Practice Address - Phone:954-642-1013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty