Provider Demographics
NPI:1134109739
Name:DENTAL ASSOCIATES OF MANCHESTER
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF MANCHESTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEHNKEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDA,BS
Authorized Official - Phone:563-927-6038
Mailing Address - Street 1:120 E FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1705
Mailing Address - Country:US
Mailing Address - Phone:563-927-4746
Mailing Address - Fax:563-927-6217
Practice Address - Street 1:120 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1705
Practice Address - Country:US
Practice Address - Phone:563-927-4746
Practice Address - Fax:563-927-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN45928OtherWELLMARK BLUE DENTAL
IA0266734Medicaid