Provider Demographics
NPI:1720696420
Name:COASTAL MONMOUTH DENTAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:COASTAL MONMOUTH DENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-531-4411
Mailing Address - Street 1:1300 STATE ROUTE 35
Mailing Address - Street 2:PLAZA 1 SUITE 202
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712
Mailing Address - Country:US
Mailing Address - Phone:732-531-4411
Mailing Address - Fax:732-531-3350
Practice Address - Street 1:1300 STATE ROUTE 35
Practice Address - Street 2:PLAZA 1 SUITE 202
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712
Practice Address - Country:US
Practice Address - Phone:732-531-4411
Practice Address - Fax:732-531-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-19
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty