Provider Demographics
NPI:1356585566
Name:PALM COAST DENTAL, LLC
Entity type:Organization
Organization Name:PALM COAST DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THAI
Authorized Official - Middle Name:THANH
Authorized Official - Last Name:NONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-237-5917
Mailing Address - Street 1:5234 E. HIGHWAY 100
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164
Mailing Address - Country:US
Mailing Address - Phone:386-263-2936
Mailing Address - Fax:386-263-2941
Practice Address - Street 1:5234 E. HIGHWAY 100
Practice Address - Street 2:SUITE 103
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164
Practice Address - Country:US
Practice Address - Phone:386-263-2936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty