Organization
COASTKIDS PEDIATRIC DENTISTRY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LANETTE L HENRY RDH (OFFICE ADMINISTRATOR)
(228) 896-5197
Entity
Organization
Contact information
Practice address
1635 E PASS RD, GULFPORT, MS 39507-3527
(228) 896-5197
Mailing address
1635 E PASS RD, GULFPORT, MS 39507-3527
(228) 896-5197
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
2005-83
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05579706
—
MS
05
—
07734393
—
MS
Enumeration date
09/08/2016
Last updated
09/08/2016
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