Provider Demographics
NPI:1891361135
Name:COAST DENTAL P.A.
Entity Type:Organization
Organization Name:COAST DENTAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-350-7166
Mailing Address - Street 1:5706 BENJAMIN CENTER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5262
Mailing Address - Country:US
Mailing Address - Phone:813-288-1999
Mailing Address - Fax:
Practice Address - Street 1:1321 NW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2139
Practice Address - Country:US
Practice Address - Phone:772-343-0179
Practice Address - Fax:772-878-4862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COAST DENTAL P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty