Provider Demographics
NPI:1376766006
Name:SOUTH COAST DENTAL SPECIALTIES
Entity Type:Organization
Organization Name:SOUTH COAST DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-363-2540
Mailing Address - Street 1:30190 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-363-2540
Mailing Address - Fax:949-363-3352
Practice Address - Street 1:30140 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677
Practice Address - Country:US
Practice Address - Phone:949-363-2540
Practice Address - Fax:949-363-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental