Provider Demographics
NPI:1689606733
Name:CRYSTAL COAST DENTISTRY
Entity Type:Organization
Organization Name:CRYSTAL COAST DENTISTRY
Other - Org Name:HAROLD & SHOLAR, D.D.S., PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-393-8168
Mailing Address - Street 1:202 WB MCLEAN DR.
Mailing Address - Street 2:
Mailing Address - City:CAPE CARTERET
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8524
Mailing Address - Country:US
Mailing Address - Phone:252-393-8168
Mailing Address - Fax:252-393-2978
Practice Address - Street 1:202 WB MCLEAN DR.
Practice Address - Street 2:
Practice Address - City:CAPE CARTERET
Practice Address - State:NC
Practice Address - Zip Code:28584-8524
Practice Address - Country:US
Practice Address - Phone:252-393-8168
Practice Address - Fax:252-393-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1680321OtherUNITED CONCORDIA
NC89016T6Medicaid
NC016T6OtherNORTH CAROLINA BCBS