Provider Demographics
NPI:1447602016
Name:ICELY, JONATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:ICELY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 W ARROYO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-8152
Mailing Address - Country:US
Mailing Address - Phone:520-344-2696
Mailing Address - Fax:
Practice Address - Street 1:9000 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7400
Practice Address - Country:US
Practice Address - Phone:520-297-2007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009525122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist