Provider Demographics
NPI:1083881270
Name:BRUCE A D'AGOSTINO DDS PC
Entity Type:Organization
Organization Name:BRUCE A D'AGOSTINO DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-652-3811
Mailing Address - Street 1:402 W PLATT ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2161
Mailing Address - Country:US
Mailing Address - Phone:563-652-3811
Mailing Address - Fax:563-652-3187
Practice Address - Street 1:402 W PLATT ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2161
Practice Address - Country:US
Practice Address - Phone:563-652-3811
Practice Address - Fax:563-652-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA64711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1164376Medicaid