Provider Demographics
NPI: | 1821283557 |
---|---|
Name: | DR. GEOFFREY A. IVERSON, D.D.S., LTD. |
Entity Type: | Organization |
Organization Name: | DR. GEOFFREY A. IVERSON, D.D.S., LTD. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | GEOFFREY |
Authorized Official - Middle Name: | ALLEN |
Authorized Official - Last Name: | IVERSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 507-364-7424 |
Mailing Address - Street 1: | 223 1ST ST S |
Mailing Address - Street 2: | P.O. BOX 23 |
Mailing Address - City: | MONTGOMERY |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56069-1601 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 507-364-7424 |
Mailing Address - Fax: | 507-364-7727 |
Practice Address - Street 1: | 223 1ST ST S |
Practice Address - Street 2: | |
Practice Address - City: | MONTGOMERY |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56069-1601 |
Practice Address - Country: | US |
Practice Address - Phone: | 507-364-7424 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-09-06 |
Last Update Date: | 2007-09-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 9174 | 261Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |