Provider Demographics
NPI:1457499758
Name:ENT PROFESSIONAL SERVICES, PC
Entity Type:Organization
Organization Name:ENT PROFESSIONAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:DVORAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-359-1646
Mailing Address - Street 1:3385 DEXTER CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3471
Mailing Address - Country:US
Mailing Address - Phone:563-359-1646
Mailing Address - Fax:563-344-6703
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:SUITE 101
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-359-1646
Practice Address - Fax:563-344-6703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA21668Medicare ID - Type Unspecified