Provider Demographics
NPI:1629543707
Name:PELOTON DENTAL SERVICES LLC
Entity Type:Organization
Organization Name:PELOTON DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-610-3505
Mailing Address - Street 1:1032 NW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-7831
Mailing Address - Country:US
Mailing Address - Phone:319-610-3505
Mailing Address - Fax:
Practice Address - Street 1:1630 SW WHITE BIRCH CIR
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7213
Practice Address - Country:US
Practice Address - Phone:515-965-4470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty