Provider Demographics
NPI:1659565349
Name:INGERSOLL DENTAL GROUP PC
Entity Type:Organization
Organization Name:INGERSOLL DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-274-5151
Mailing Address - Street 1:3830 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3413
Mailing Address - Country:US
Mailing Address - Phone:515-274-5151
Mailing Address - Fax:515-274-6259
Practice Address - Street 1:3830 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3413
Practice Address - Country:US
Practice Address - Phone:515-274-5151
Practice Address - Fax:515-274-6259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1480590Medicaid
IA1481259Medicaid