Provider Demographics
NPI:1063756401
Name:BANDON COASTAL DENTAL, LLC
Entity type:Organization
Organization Name:BANDON COASTAL DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:PANTLEO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-329-0550
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:1097 BALTIMORE AVE
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411
Mailing Address - Country:US
Mailing Address - Phone:541-329-0550
Mailing Address - Fax:541-329-0309
Practice Address - Street 1:1097 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411
Practice Address - Country:US
Practice Address - Phone:541-329-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9802261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center