Provider Demographics
NPI:1063616134
Name:COASTAL DENTAL CARE
Entity type:Organization
Organization Name:COASTAL DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-882-9602
Mailing Address - Street 1:368 CHARLIE SMITH SR HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3101
Mailing Address - Country:US
Mailing Address - Phone:912-882-9602
Mailing Address - Fax:912-882-7564
Practice Address - Street 1:368 CHARLIE SMITH SR HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3101
Practice Address - Country:US
Practice Address - Phone:912-882-9602
Practice Address - Fax:912-882-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1646968OtherUNITED CONCORDIA