Provider Demographics
NPI:1457735995
Name:COASTAL ORAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:COASTAL ORAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:CAPES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-634-6600
Mailing Address - Street 1:110 OFFICE PARK LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-6601
Mailing Address - Country:US
Mailing Address - Phone:912-634-6600
Mailing Address - Fax:912-634-3882
Practice Address - Street 1:110 OFFICE PARK LN
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-6601
Practice Address - Country:US
Practice Address - Phone:912-634-6600
Practice Address - Fax:912-634-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0115151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty