Provider Demographics
NPI:1023285202
Name:COSMETIC AND FAMILY DENTISTRY
Entity type:Organization
Organization Name:COSMETIC AND FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:712-792-6455
Mailing Address - Street 1:2008 N US HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3300
Mailing Address - Country:US
Mailing Address - Phone:712-792-6455
Mailing Address - Fax:
Practice Address - Street 1:2008 N US HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3300
Practice Address - Country:US
Practice Address - Phone:712-792-6455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA78061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0132613Medicaid