Provider Demographics
NPI:1972023414
Name:IOWA DERMATOLOGY CLINIC PLC
Entity Type:Organization
Organization Name:IOWA DERMATOLOGY CLINIC PLC
Other - Org Name:RADIANT COMPLEXIONS DERMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-226-8484
Mailing Address - Street 1:6800 LAKE DR STE 285
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2544
Mailing Address - Country:US
Mailing Address - Phone:515-226-3116
Mailing Address - Fax:888-391-9262
Practice Address - Street 1:9500 UNIVERSITY AVE STE 1114
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1745
Practice Address - Country:US
Practice Address - Phone:515-221-8960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty