Provider Demographics
NPI:1497629836
Name:WEST COAST DENTAL PARTNERS
Entity type:Organization
Organization Name:WEST COAST DENTAL PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANALEJO HILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-389-4724
Mailing Address - Street 1:1060 S US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5237
Mailing Address - Country:US
Mailing Address - Phone:352-290-6001
Mailing Address - Fax:
Practice Address - Street 1:1060 S US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5237
Practice Address - Country:US
Practice Address - Phone:352-290-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COAST DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty