Provider Demographics
NPI:1598210619
Name:CENTRAL COAST DENTAL INC
Entity Type:Organization
Organization Name:CENTRAL COAST DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-528-7266
Mailing Address - Street 1:85 N 100 E
Mailing Address - Street 2:STE B
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0400
Mailing Address - Country:US
Mailing Address - Phone:435-528-7266
Mailing Address - Fax:
Practice Address - Street 1:85 N 100 E
Practice Address - Street 2:STE B
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-0400
Practice Address - Country:US
Practice Address - Phone:435-528-7266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty