Provider Demographics
NPI:1619494333
Name:SERGEANT BLUFF DENTAL, PC
Entity Type:Organization
Organization Name:SERGEANT BLUFF DENTAL, PC
Other - Org Name:SERGEANT BLUFF DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-943-4242
Mailing Address - Street 1:703 1ST ST
Mailing Address - Street 2:PO BOX 280
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054
Mailing Address - Country:US
Mailing Address - Phone:712-943-4242
Mailing Address - Fax:712-943-4243
Practice Address - Street 1:703 1ST ST
Practice Address - Street 2:PO BOX 280
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054
Practice Address - Country:US
Practice Address - Phone:712-943-4242
Practice Address - Fax:712-943-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty