Basic Information
| Provider Information | |||||||||
| NPI: | 1154541845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | JADE | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 238 TAHITI RD | ||||||||
| Address2: | |||||||||
| City: | MARCO ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393442322 | ||||||||
| FaxNumber: | 2393900523 | ||||||||
| Practice Location | |||||||||
| Address1: | 28321 S. TAMIAMI TRAIL | ||||||||
| Address2: | SUITE A1-2 | ||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393442322 | ||||||||
| FaxNumber: | 2393900523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN18068 | FL | N | Dental Providers | Dentist | 1223G0001X | 3736 | ME | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 418040000 | 05 | ME | MEDICAID |