Provider Demographics
NPI:1558816991
Name:COAST DENTAL OF SOUTH GEORGIA PC
Entity Type:Organization
Organization Name:COAST DENTAL OF SOUTH GEORGIA PC
Other - Org Name:COAST DENTAL- FORT STEWART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF INS. AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-288-1999
Mailing Address - Street 1:4010 W BOY SCOUT BLVD
Mailing Address - Street 2:SUITE 1100- CREDENTIALING
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5727
Mailing Address - Country:US
Mailing Address - Phone:813-288-1999
Mailing Address - Fax:813-434-2325
Practice Address - Street 1:4010 W BOY SCOUT BLVD
Practice Address - Street 2:SUITE 1100- CREDENTIALING
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5727
Practice Address - Country:US
Practice Address - Phone:813-288-1999
Practice Address - Fax:813-434-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-15
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty