Provider Demographics
NPI:1285188128
Name:ICENOGLE, ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ICENOGLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 W HORIZON AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-8493
Mailing Address - Country:US
Mailing Address - Phone:509-954-5625
Mailing Address - Fax:
Practice Address - Street 1:3415 W HORIZON AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8493
Practice Address - Country:US
Practice Address - Phone:509-954-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 606676081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice