Provider Demographics
NPI:1649387333
Name:FAMILY FIRST DENTAL OF PRIMGHAR PC
Entity Type:Organization
Organization Name:FAMILY FIRST DENTAL OF PRIMGHAR PC
Other - Org Name:PRIMGHAR DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-957-2460
Mailing Address - Street 1:BOX 278
Mailing Address - Street 2:135 1ST STREET NW
Mailing Address - City:PRIMGHAR
Mailing Address - State:IA
Mailing Address - Zip Code:51245
Mailing Address - Country:US
Mailing Address - Phone:712-957-2460
Mailing Address - Fax:712-957-1013
Practice Address - Street 1:135 1ST STREET NW
Practice Address - Street 2:BOX 278
Practice Address - City:PRIMGHAR
Practice Address - State:IA
Practice Address - Zip Code:51245
Practice Address - Country:US
Practice Address - Phone:712-957-2460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1152553Medicaid