Healthcare Provider Details

I. General information

NPI: 1356835839
Provider Name (Legal Business Name): ILONA ZBIRUN NOCKLES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS BLUE RIDGE (LCC-19) UNIT 100102, BOX ADMIN
FPO AP
96628
US

IV. Provider business mailing address

3313 LINCOLN AVE
SAN DIEGO CA
92104-2111
US

V. Phone/Fax

Practice location:
  • Phone: 917-562-2747
  • Fax:
Mailing address:
  • Phone: 917-562-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: