Provider Demographics
NPI:1275618886
Name:PEDIATRIC DENTISTRY OF CENTRAL IOWA, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CENTRAL IOWA, P.C.
Other - Org Name:PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-223-1298
Mailing Address - Street 1:1000 73RD ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50324-1321
Mailing Address - Country:US
Mailing Address - Phone:515-223-1298
Mailing Address - Fax:515-223-1959
Practice Address - Street 1:1000 73RD ST
Practice Address - Street 2:SUITE 10
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50324-1321
Practice Address - Country:US
Practice Address - Phone:515-223-1298
Practice Address - Fax:515-223-1959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty