Provider Demographics
NPI:1972855179
Name:COUGHLIN, NATHAN DANIEL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DANIEL JAMES
Last Name:COUGHLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 MARINA CITY DR UNIT 743
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5847
Mailing Address - Country:US
Mailing Address - Phone:323-898-3102
Mailing Address - Fax:
Practice Address - Street 1:4150 E RENNER RD STE 400
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2820
Practice Address - Country:US
Practice Address - Phone:972-248-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist