Provider Demographics
NPI:1437284270
Name:COASTAL COSMETIC DENTAL ASSOCIATES,
Entity Type:Organization
Organization Name:COASTAL COSMETIC DENTAL ASSOCIATES,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAN WIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-249-4092
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0635
Mailing Address - Country:US
Mailing Address - Phone:843-249-4092
Mailing Address - Fax:843-249-1638
Practice Address - Street 1:1247 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9211
Practice Address - Country:US
Practice Address - Phone:843-249-4092
Practice Address - Fax:843-249-1638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty