Provider Demographics
NPI:1497035273
Name:GULF COAST DENTISTRY
Entity Type:Organization
Organization Name:GULF COAST DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:251-948-9313
Mailing Address - Street 1:313 E 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-3193
Mailing Address - Country:US
Mailing Address - Phone:251-948-9313
Mailing Address - Fax:251-948-8383
Practice Address - Street 1:313 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-3193
Practice Address - Country:US
Practice Address - Phone:251-948-9313
Practice Address - Fax:251-948-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009924875Medicaid