Healthcare Provider Details

I. General information

NPI: 1477747111
Provider Name (Legal Business Name): STEVEN D ICELAND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 REYES ADOBE ROAD SUITE A
AGOURA HILLS CA
91301-2083
US

IV. Provider business mailing address

5353 REYES ADOBE ROAD SUITE A
AGOURA HILLS CA
91301-2083
US

V. Phone/Fax

Practice location:
  • Phone: 818-991-5004
  • Fax: 818-991-3996
Mailing address:
  • Phone: 818-991-5004
  • Fax: 818-991-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number24670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: