Provider Demographics
NPI:1013215805
Name:SOUTHWEST IOWA DENTAL ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTHWEST IOWA DENTAL ASSOCIATES INC
Other - Org Name:SOUTHWEST IOWA DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-246-2180
Mailing Address - Street 1:1213 W NISHNA RD
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2115
Mailing Address - Country:US
Mailing Address - Phone:712-246-2180
Mailing Address - Fax:712-246-1683
Practice Address - Street 1:1213 W NISHNA RD
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2115
Practice Address - Country:US
Practice Address - Phone:712-246-2180
Practice Address - Fax:712-246-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty