Provider Demographics
NPI:1922562438
Name:COASTAL ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:COASTAL ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-853-1142
Mailing Address - Street 1:PO BOX 20068
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-0068
Mailing Address - Country:US
Mailing Address - Phone:985-853-1142
Mailing Address - Fax:985-853-1143
Practice Address - Street 1:635 ENTERPRISE DRIVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-7036
Practice Address - Country:US
Practice Address - Phone:985-853-1142
Practice Address - Fax:985-853-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty