Provider Demographics
NPI:1770633257
Name:ISLAND ORTHODONTICS
Entity Type:Organization
Organization Name:ISLAND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-477-9283
Mailing Address - Street 1:800 MATLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9126
Mailing Address - Country:US
Mailing Address - Phone:817-477-9283
Mailing Address - Fax:817-453-5710
Practice Address - Street 1:800 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9126
Practice Address - Country:US
Practice Address - Phone:817-477-9283
Practice Address - Fax:817-453-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12577 11979 122251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty