# COASTKIDS PEDIATRIC DENTISTRY, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1093262974
- **Authorized official:** LANETTE L HENRY RDH (OFFICE ADMINISTRATOR)
- **Authorized official phone:** (228) 896-5197

## Contact information

- **Practice address:** 1635 E PASS RD, GULFPORT, MS 39507-3527
- **Practice address phone:** (228) 896-5197
- **Mailing address:** 1635 E PASS RD, GULFPORT, MS 39507-3527
- **Mailing address phone:** (228) 896-5197

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 2005-83 | MS | Yes |

## Other

- **Enumeration date:** 09/08/2016
- **Last updated:** 09/08/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 05579706 | — | MS |
| 05 | — | 07734393 | — | MS |