Provider Demographics
NPI:1750123345
Name:ISHAK, GRACE (DMD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ISHAK
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 1:2616 DERBY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-2006
Mailing Address - Country:US
Mailing Address - Phone:813-325-1310
Mailing Address - Fax:
Practice Address - Street 1:9200 113TH ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2800
Practice Address - Country:US
Practice Address - Phone:727-893-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist