Provider Demographics
NPI:1831587260
Name:COASTAL DENTAL ASSOCIATES III, LLC
Entity type:Organization
Organization Name:COASTAL DENTAL ASSOCIATES III, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-931-2196
Mailing Address - Street 1:20 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-1204
Mailing Address - Country:US
Mailing Address - Phone:401-423-2110
Mailing Address - Fax:401-423-9224
Practice Address - Street 1:20 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02835-1204
Practice Address - Country:US
Practice Address - Phone:401-423-2110
Practice Address - Fax:401-423-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty