Provider Demographics
NPI:1790130789
Name:GULF COAST PEDIATRIC DENTAL SPECIALISTS PLLC
Entity Type:Organization
Organization Name:GULF COAST PEDIATRIC DENTAL SPECIALISTS PLLC
Other - Org Name:GULF COAST PEDIATRIC DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLAMIDE
Authorized Official - Middle Name:OSUNDOLU
Authorized Official - Last Name:ATANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-333-0909
Mailing Address - Street 1:3121 BUFFALO SPEEDWAY APT 5307
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-1852
Mailing Address - Country:US
Mailing Address - Phone:352-333-0909
Mailing Address - Fax:
Practice Address - Street 1:6318 FM 1488 RD STE 120
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2519
Practice Address - Country:US
Practice Address - Phone:281-985-9075
Practice Address - Fax:936-448-9862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty