Provider Demographics
NPI:1205563004
Name:INTERCOASTAL DENTAL PLLC
Entity type:Organization
Organization Name:INTERCOASTAL DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRE
Authorized Official - Middle Name:EIAN
Authorized Official - Last Name:GAETA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-264-0182
Mailing Address - Street 1:104 SANTA BARBARA WAY
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11940 US 1 STE 245
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33408-2832
Practice Address - Country:US
Practice Address - Phone:626-264-0182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty