Provider Demographics
NPI:1114905387
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:HOSPITAL DENTISTRY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DEAN FINANCIAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNESON
Authorized Official - Suffix:
Authorized Official - Credentials:BBA MBA
Authorized Official - Phone:319-335-6770
Mailing Address - Street 1:200 HAWKINS DRIVE
Mailing Address - Street 2:51300 POMERANTZ FAMILY PAVILION
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1049
Mailing Address - Country:US
Mailing Address - Phone:319-356-2743
Mailing Address - Fax:319-353-6923
Practice Address - Street 1:200 HAWKINS DRIVE
Practice Address - Street 2:51300 POMERANTZ FAMILY PAVILION
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1049
Practice Address - Country:US
Practice Address - Phone:319-356-2743
Practice Address - Fax:319-353-6923
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-06
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0177832Medicaid
IA33538OtherWELLMARK MAXILLOFACIAL SP
IA33538OtherWELLMARK MAXILLOFACIAL SP