Provider Demographics
NPI:1821433145
Name:COASTAL KIDS PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:COASTAL KIDS PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DI CERBO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-733-4300
Mailing Address - Street 1:18947 JOHN J WILLIAMS HWY
Mailing Address - Street 2:SUITE 309
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-4474
Mailing Address - Country:US
Mailing Address - Phone:610-733-4300
Mailing Address - Fax:
Practice Address - Street 1:18947 JOHN J WILLIAMS HWY
Practice Address - Street 2:SUITE 309
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4474
Practice Address - Country:US
Practice Address - Phone:610-733-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00012961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821433145OtherDELTA DENTAL
271596OtherCIGNA
DE1821433145Medicaid
171999OtherGUARDIAN