Provider Demographics
NPI:1316030349
Name:CORAL WEST DENTAL P.C.
Entity Type:Organization
Organization Name:CORAL WEST DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFEREY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RUBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-545-2345
Mailing Address - Street 1:2575 CORAL COURT
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241
Mailing Address - Country:US
Mailing Address - Phone:319-545-2345
Mailing Address - Fax:319-545-2349
Practice Address - Street 1:2575 CORAL CT
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2811
Practice Address - Country:US
Practice Address - Phone:319-545-2345
Practice Address - Fax:319-545-2349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA74191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2285676Medicaid