Organization
COASTAL PALM ORTHODONTICS LLC
Active
Organization
COASTAL PALM ORTHODONTICS LLC
Active
Other names
Coastal Palm Orthodontics
Organization subpart
No
Provider details
NPI number
Authorized official
RUSSELL BLAKE MCCRACKEN DMD (OWNER)
(843) 697-1423
Entity
Organization
Contact information
Practice address
1255 TADLOCK DR UNIT B, MURRELLS INLET, SC 29576-7973
(843) 697-1423
Mailing address
25 OLD BARGE DR, PAWLEYS ISLAND, SC 29585-6345
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Enumeration date
05/22/2024
Last updated
05/22/2024
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