Provider Demographics
NPI:1720546476
Name:EDP OF IOWA PC
Entity Type:Organization
Organization Name:EDP OF IOWA PC
Other - Org Name:DONA PRINCE DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF INTEGRATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROSEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNENKANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-937-3619
Mailing Address - Street 1:141 W JACKSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3048
Mailing Address - Country:US
Mailing Address - Phone:312-937-3619
Mailing Address - Fax:
Practice Address - Street 1:4220 SERGEANT RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4648
Practice Address - Country:US
Practice Address - Phone:312-800-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDP OF IOWA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-12
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty