Provider Demographics
NPI:1336485424
Name:PRAIRIE TRAILS FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:PRAIRIE TRAILS FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-872-5341
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IA
Mailing Address - Zip Code:50060-0284
Mailing Address - Country:US
Mailing Address - Phone:641-872-2514
Mailing Address - Fax:641-872-1152
Practice Address - Street 1:100 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IA
Practice Address - Zip Code:50060-1724
Practice Address - Country:US
Practice Address - Phone:641-872-2514
Practice Address - Fax:641-872-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty