Provider Demographics
NPI:1568875250
Name:GULF COAST DENTAL - BAY CITY
Entity Type:Organization
Organization Name:GULF COAST DENTAL - BAY CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIEP
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-245-2104
Mailing Address - Street 1:PO BOX 1569
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-1569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2521 AVENUE H
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-6029
Practice Address - Country:US
Practice Address - Phone:979-245-2104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OCEANSIDE DENTAL ARTS, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17862122300000X
TX12472122300000X
TX24866122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty