Provider Demographics
NPI:1003134776
Name:COUNTRYSIDE DENTAL CARE LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-224-1618
Mailing Address - Street 1:1903 EP TRUE PKWY # S301
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-7000
Mailing Address - Country:US
Mailing Address - Phone:515-224-1618
Mailing Address - Fax:
Practice Address - Street 1:1903 EP TRUE PKWY # S301
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-7000
Practice Address - Country:US
Practice Address - Phone:515-224-1618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty