Provider Demographics
NPI:1588821656
Name:ELDRIDGE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ELDRIDGE FAMILY DENTISTRY
Other - Org Name:R. SCOTT DANIELS, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-285-8662
Mailing Address - Street 1:201 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-1759
Mailing Address - Country:US
Mailing Address - Phone:563-285-8662
Mailing Address - Fax:563-285-1337
Practice Address - Street 1:201 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:IA
Practice Address - Zip Code:52748-1759
Practice Address - Country:US
Practice Address - Phone:563-285-8662
Practice Address - Fax:563-285-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7239122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0056093Medicaid
IA0056085Medicaid