Provider Demographics
NPI:1336206515
Name:AGAPE DENTISTRY, PLC
Entity Type:Organization
Organization Name:AGAPE DENTISTRY, PLC
Other - Org Name:ADDINK & VAN ES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-722-2618
Mailing Address - Street 1:159 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1535
Mailing Address - Country:US
Mailing Address - Phone:712-722-2618
Mailing Address - Fax:712-722-2638
Practice Address - Street 1:159 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1535
Practice Address - Country:US
Practice Address - Phone:712-722-2618
Practice Address - Fax:712-722-2638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0739029Medicaid