Provider Demographics
NPI:1699025809
Name:ISLAND DENTAL,PA
Entity Type:Organization
Organization Name:ISLAND DENTAL,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:VALDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-454-0959
Mailing Address - Street 1:900 N FEDERAL HWY
Mailing Address - Street 2:STE 308
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2546
Mailing Address - Country:US
Mailing Address - Phone:954-454-0959
Mailing Address - Fax:954-454-0969
Practice Address - Street 1:900 N. FEDERAL HWY
Practice Address - Street 2:STE 308
Practice Address - City:HALLANDALE
Practice Address - State:FL
Practice Address - Zip Code:33009
Practice Address - Country:US
Practice Address - Phone:954-454-0959
Practice Address - Fax:954-454-0969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 162271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty