Provider Demographics
NPI:1982182606
Name:DENTAL STUDIO OF IOWA PC
Entity Type:Organization
Organization Name:DENTAL STUDIO OF IOWA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-707-4383
Mailing Address - Street 1:905 NW HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-2300
Mailing Address - Country:US
Mailing Address - Phone:515-707-4383
Mailing Address - Fax:
Practice Address - Street 1:5495 NW 100TH STREET
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131
Practice Address - Country:US
Practice Address - Phone:515-707-4383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1013329978Medicaid
IA1942615232Medicaid