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General NPI Number Information
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NPI Number | 1780880880
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Entity Type | Organization
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Legal Business Name | ISLAND DENTAL
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Dates
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Enumeration Date | 06/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1489 W ELLIOT RD STE 101
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City | GILBERT
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State | AZ
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Zip | 85233-5168
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Country | US
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Telephone | 480-507-9400
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Fax | 480-507-9474
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Provider Business Mailing Address
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Address Line | 1489 W ELLIOT RD STE 101
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City | GILBERT
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State | AZ
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Zip | 85233-5168
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Country | US
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Telephone | 480-507-9400
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Fax | 480-507-9474
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Authorized Official
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Title or Position | OWNER
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Name | DR. LYDE JEFFERSON ADAMS
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Credential | DDS
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Telephone | 480-507-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | AZ5662
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License Number State | AZ
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