Provider Demographics
NPI:1164596953
Name:DOSLAND, DERALD DEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERALD
Middle Name:DEAN
Last Name:DOSLAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4213
Mailing Address - Country:US
Mailing Address - Phone:563-243-6950
Mailing Address - Fax:563-243-2648
Practice Address - Street 1:400 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4213
Practice Address - Country:US
Practice Address - Phone:563-243-6950
Practice Address - Fax:563-243-2648
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA58181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
845565OtherUNITED CONCORDIA
IA0133819Medicare ID - Type Unspecified