Provider Demographics
NPI:1548415144
Name:EMERALD COAST DENTAL SPA
Entity Type:Organization
Organization Name:EMERALD COAST DENTAL SPA
Other - Org Name:TARA WALLING DMD PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:850-249-9311
Mailing Address - Street 1:900 THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7442
Mailing Address - Country:US
Mailing Address - Phone:850-249-9311
Mailing Address - Fax:850-249-9312
Practice Address - Street 1:900 THOMAS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-7442
Practice Address - Country:US
Practice Address - Phone:850-249-9311
Practice Address - Fax:850-249-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
FL17668305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty