Provider Demographics
NPI:1639595952
Name:IOWA PEDIATRIC DENTAL CENTER
Entity Type:Organization
Organization Name:IOWA PEDIATRIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-351-5439
Mailing Address - Street 1:501 12TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1774
Mailing Address - Country:US
Mailing Address - Phone:319-351-5439
Mailing Address - Fax:319-354-0491
Practice Address - Street 1:501 12TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1774
Practice Address - Country:US
Practice Address - Phone:319-351-5439
Practice Address - Fax:319-354-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty