Provider Demographics
NPI:1699928267
Name:COASTAL FAMILY DENTISTRY OF JOHNS ISLAND
Entity type:Organization
Organization Name:COASTAL FAMILY DENTISTRY OF JOHNS ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-559-5555
Mailing Address - Street 1:2754 MAYBANK HWY
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-4809
Mailing Address - Country:US
Mailing Address - Phone:843-559-5555
Mailing Address - Fax:
Practice Address - Street 1:2754 MAYBANK HWY
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-4809
Practice Address - Country:US
Practice Address - Phone:843-559-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3539122300000X
SC3298122300000X
SC4360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty