Provider Demographics
NPI:1508023375
Name:PEOSTA DENTAL
Entity Type:Organization
Organization Name:PEOSTA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:BARRETT
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-557-1563
Mailing Address - Street 1:8558 KAPP DR
Mailing Address - Street 2:
Mailing Address - City:PEOSTA
Mailing Address - State:IA
Mailing Address - Zip Code:52068-9759
Mailing Address - Country:US
Mailing Address - Phone:563-557-1563
Mailing Address - Fax:563-583-0581
Practice Address - Street 1:8558 KAPP DR
Practice Address - Street 2:
Practice Address - City:PEOSTA
Practice Address - State:IA
Practice Address - Zip Code:52068-9759
Practice Address - Country:US
Practice Address - Phone:563-557-1563
Practice Address - Fax:563-583-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0493965Medicaid