Healthcare Provider Details

I. General information

NPI: 1699526590
Provider Name (Legal Business Name): ISLAND HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MARINERS LNDG UNIT D
EDGARTOWN MA
02539-7056
US

IV. Provider business mailing address

PO BOX 9000
EDGARTOWN MA
02539-9000
US

V. Phone/Fax

Practice location:
  • Phone: 508-627-5797
  • Fax: 508-939-8644
Mailing address:
  • Phone: 508-627-5797
  • Fax: 508-939-8644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA MITCHELL
Title or Position: CEO
Credential:
Phone: 508-627-5797