Provider Demographics
NPI:1619135696
Name:PETER J PAULY DDS PC
Entity Type:Organization
Organization Name:PETER J PAULY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAULY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-872-5678
Mailing Address - Street 1:400 S RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:IA
Mailing Address - Zip Code:52031-1350
Mailing Address - Country:US
Mailing Address - Phone:563-872-5678
Mailing Address - Fax:
Practice Address - Street 1:400 S RIVERVIEW ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:IA
Practice Address - Zip Code:52031-1350
Practice Address - Country:US
Practice Address - Phone:563-872-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6336261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0150383Medicaid