Provider Demographics
NPI:1942813738
Name:WEST COAST ENDODONTICS
Entity Type:Organization
Organization Name:WEST COAST ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-787-4005
Mailing Address - Street 1:2654 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3120
Mailing Address - Country:US
Mailing Address - Phone:727-787-4005
Mailing Address - Fax:727-490-4421
Practice Address - Street 1:2654 W LAKE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3120
Practice Address - Country:US
Practice Address - Phone:727-787-4005
Practice Address - Fax:727-490-4421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty