Healthcare Provider Details

I. General information

NPI: 1750123345
Provider Name (Legal Business Name): GRACE ISHAK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8325 GUNN HWY
TAMPA FL
33626-1608
US

IV. Provider business mailing address

2616 DERBY GLEN DR
LUTZ FL
33559-2006
US

V. Phone/Fax

Practice location:
  • Phone: 813-413-7758
  • Fax:
Mailing address:
  • Phone: 813-325-1310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDRPM2745
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: