Healthcare Provider Details

I. General information

NPI: 1447602016
Provider Name (Legal Business Name): JONATHAN ICELY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 N ORACLE RD
TUCSON AZ
85704-7400
US

IV. Provider business mailing address

1821 W ARROYO VISTA DR
TUCSON AZ
85746-8152
US

V. Phone/Fax

Practice location:
  • Phone: 520-297-2007
  • Fax:
Mailing address:
  • Phone: 520-344-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: