Provider Demographics
NPI:1083453278
Name:ISLAND ORTHODONTICS MOBILE
Entity type:Organization
Organization Name:ISLAND ORTHODONTICS MOBILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHDONTIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DYKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-223-3896
Mailing Address - Street 1:4720 AIPORT BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608
Mailing Address - Country:US
Mailing Address - Phone:251-344-7604
Mailing Address - Fax:
Practice Address - Street 1:4720 AIPORT BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:251-344-7604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty