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General NPI Number Information
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NPI Number | 1770633257
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Entity Type | Organization
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Legal Business Name | ISLAND ORTHODONTICS
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 800 MATLOCK RD
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City | MANSFIELD
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State | TX
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Zip | 76063-9126
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Country | US
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Telephone | 817-477-9283
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Fax | 817-453-5710
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Provider Business Mailing Address
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Address Line | 800 MATLOCK RD
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City | MANSFIELD
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State | TX
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Zip | 76063-9126
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Country | US
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Telephone | 817-477-9283
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Fax | 817-453-5710
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. SHERRI SMITH
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Credential |
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Telephone | 817-477-9283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12577 11979 12225
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License Number State | TX
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