Provider Demographics
NPI:1164761698
Name:DIAMOND TRAIL DENTAL PC
Entity Type:Organization
Organization Name:DIAMOND TRAIL DENTAL PC
Other - Org Name:DIAMOND TRAIL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:DEBOEF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-673-3008
Mailing Address - Street 1:107 HIGH AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-2831
Mailing Address - Country:US
Mailing Address - Phone:641-673-3008
Mailing Address - Fax:641-672-8807
Practice Address - Street 1:301 S. 4TH ST.
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:IA
Practice Address - Zip Code:50171-1031
Practice Address - Country:US
Practice Address - Phone:641-623-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental