Provider Demographics
NPI:1154016178
Name:ISLAND TOWER DENTISTRY PA
Entity type:Organization
Organization Name:ISLAND TOWER DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MA
Authorized Official - Phone:239-394-1004
Mailing Address - Street 1:606 BALD EAGLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2731
Mailing Address - Country:US
Mailing Address - Phone:239-394-1004
Mailing Address - Fax:
Practice Address - Street 1:606 BALD EAGLE DR STE 200
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-2731
Practice Address - Country:US
Practice Address - Phone:239-394-1004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty