Provider Demographics
NPI:1972081941
Name:COASTAL CAROLINA COSMETIC FACIAL SURGERY
Entity Type:Organization
Organization Name:COASTAL CAROLINA COSMETIC FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-201-5801
Mailing Address - Street 1:6210 N OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-3300
Mailing Address - Country:US
Mailing Address - Phone:720-201-5801
Mailing Address - Fax:
Practice Address - Street 1:133 TOWNE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3493
Practice Address - Country:US
Practice Address - Phone:843-448-1621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8911261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery