Provider Demographics
NPI:1881007946
Name:INTERCOASTAL ENDO, PC
Entity Type:Organization
Organization Name:INTERCOASTAL ENDO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:CONARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-449-4900
Mailing Address - Street 1:4382 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577
Mailing Address - Country:US
Mailing Address - Phone:843-449-4900
Mailing Address - Fax:843-449-1658
Practice Address - Street 1:4382 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-449-4900
Practice Address - Fax:843-449-1658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46171223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty