Provider Demographics
NPI:1417961376
Name:GULF COAST DENTAL CARE PLLC
Entity type:Organization
Organization Name:GULF COAST DENTAL CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:COVINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-832-3231
Mailing Address - Street 1:15503 OAK LN STE 300B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2697
Mailing Address - Country:US
Mailing Address - Phone:228-832-3231
Mailing Address - Fax:228-832-0186
Practice Address - Street 1:15503 OAK LN # 300B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2697
Practice Address - Country:US
Practice Address - Phone:228-832-3231
Practice Address - Fax:228-832-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS985280OtherUNITED CONCORDIA