Provider Demographics
NPI:1790096402
Name:SOUTH COAST DENTAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTH COAST DENTAL GROUP LLC
Other - Org Name:SOUTH COAST FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING & CLAIMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:I
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-269-5353
Mailing Address - Street 1:295 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-4623
Mailing Address - Country:US
Mailing Address - Phone:541-269-5353
Mailing Address - Fax:541-266-0933
Practice Address - Street 1:295 S 10TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4623
Practice Address - Country:US
Practice Address - Phone:541-269-5353
Practice Address - Fax:541-266-0933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9399122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6598620001Medicare NSC
OR6598620001Medicare NSC