Provider Demographics
NPI:1679773899
Name:COASTAL FAMILY DENTISTRY
Entity Type:Organization
Organization Name:COASTAL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-881-1418
Mailing Address - Street 1:3098 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9315
Mailing Address - Country:US
Mailing Address - Phone:843-881-1418
Mailing Address - Fax:
Practice Address - Street 1:3098 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9315
Practice Address - Country:US
Practice Address - Phone:843-881-1418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35391223G0001X
SC32981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty