Provider Demographics
NPI:1003919135
Name:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Other - Org Name:FAMILY DENTISTRY ASSOCIATES OF MONONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-568-3983
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:IA
Mailing Address - Zip Code:52159
Mailing Address - Country:US
Mailing Address - Phone:563-539-4651
Mailing Address - Fax:563-539-4653
Practice Address - Street 1:101 FRANKLIN
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:IA
Practice Address - Zip Code:52159
Practice Address - Country:US
Practice Address - Phone:563-539-4651
Practice Address - Fax:563-539-4653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-06
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty