Provider Demographics
NPI:1235360975
Name:WESTDALE DENTAL OFFICE
Entity Type:Organization
Organization Name:WESTDALE DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-396-0700
Mailing Address - Street 1:4135 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-6342
Mailing Address - Country:US
Mailing Address - Phone:319-396-0700
Mailing Address - Fax:319-396-4410
Practice Address - Street 1:4135 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-6342
Practice Address - Country:US
Practice Address - Phone:319-396-0700
Practice Address - Fax:319-396-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA67001223G0001X
IA081121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty