Provider Demographics
NPI:1366796450
Name:CORAL DENTAL AND DENTURE PA
Entity type:Organization
Organization Name:CORAL DENTAL AND DENTURE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:CASTELLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:239-603-5210
Mailing Address - Street 1:12711 MCGREGOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4412
Mailing Address - Country:US
Mailing Address - Phone:239-542-3925
Mailing Address - Fax:239-210-5903
Practice Address - Street 1:12711 MCGREGOR BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4412
Practice Address - Country:US
Practice Address - Phone:239-542-3925
Practice Address - Fax:239-210-5903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19837261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental