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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