MEDICARE: ELLIOT ROAD DENTAL - ISLAND PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1639846165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLIOT ROAD DENTAL - ISLAND PLLC

Provider Business Mailing Address
First Line	:	1489 W ELLIOT RD STE 101
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-5168
Country	:	US
Telephone Number	:	480-507-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1489 W ELLIOT RD STE 101
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-5168
Country	:	US
Telephone Number	:	480-507-9400
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING DIRECTOR
Name	:	FAITH GASKINS
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	08/24/2021

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