Provider Demographics
NPI:1841574886
Name:WESTERN IOWA DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:WESTERN IOWA DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JOANN
Authorized Official - Last Name:KERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-325-1544
Mailing Address - Street 1:1509 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-2516
Mailing Address - Country:US
Mailing Address - Phone:712-325-1544
Mailing Address - Fax:712-325-0420
Practice Address - Street 1:1509 AVENUE G
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-2516
Practice Address - Country:US
Practice Address - Phone:712-325-1544
Practice Address - Fax:712-325-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty