Provider Demographics
NPI:1043267883
Name:DOUGLAS J RECKER
Entity Type:Organization
Organization Name:DOUGLAS J RECKER
Other - Org Name:BOYSON DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-393-4019
Mailing Address - Street 1:1475 BOYSON ROAD
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-2339
Mailing Address - Country:US
Mailing Address - Phone:319-393-4019
Mailing Address - Fax:319-378-2924
Practice Address - Street 1:1475 BOYSON RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2339
Practice Address - Country:US
Practice Address - Phone:319-393-4019
Practice Address - Fax:319-378-2924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOUGLAS J RECKER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA74551223G0001X
IA76381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0200759OtherMEDICAID GROUP
IA0083212Medicaid
IA1123307Medicaid