Provider Demographics
NPI:1376844951
Name:ISLAND COAST DENTISTRY, INC
Entity Type:Organization
Organization Name:ISLAND COAST DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SKUPNY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-246-3177
Mailing Address - Street 1:20570 GROVELINE CT
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1044 CASTELLO DR
Practice Address - Street 2:110
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103
Practice Address - Country:US
Practice Address - Phone:239-261-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL180971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty