Provider Demographics
NPI:1154541845
Name:LE, JADE (DMD)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:LE
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 1:238 TAHITI RD
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145
Mailing Address - Country:US
Mailing Address - Phone:239-344-2322
Mailing Address - Fax:239-390-0523
Practice Address - Street 1:28321 S. TAMIAMI TRAIL
Practice Address - Street 2:SUITE A1-2
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-344-2322
Practice Address - Fax:239-390-0523
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18068122300000X
ME37361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME418040000Medicaid