Provider Demographics
NPI:1073939799
Name:WESTERN IOWA DENTAL GROUP,PC
Entity Type:Organization
Organization Name:WESTERN IOWA DENTAL GROUP,PC
Other - Org Name:BAYLISS PARK DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-325-1544
Mailing Address - Street 1:1509 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-2516
Mailing Address - Country:US
Mailing Address - Phone:712-325-1544
Mailing Address - Fax:712-325-0420
Practice Address - Street 1:114 1/2 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-4234
Practice Address - Country:US
Practice Address - Phone:712-325-1544
Practice Address - Fax:712-325-0420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN IOWA DENTAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty