Provider Demographics
NPI:1578763090
Name:OAKDALE DENTAL PC
Entity Type:Organization
Organization Name:OAKDALE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-545-6251
Mailing Address - Street 1:2441 CORAL CT STE 5
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2872
Mailing Address - Country:US
Mailing Address - Phone:319-545-6251
Mailing Address - Fax:319-545-7265
Practice Address - Street 1:2441 CORAL CT STE 5
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2872
Practice Address - Country:US
Practice Address - Phone:319-545-6251
Practice Address - Fax:319-545-7265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA80011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1219089Medicaid