Provider Demographics
NPI:1700053006
Name:FISHOMEN P.C.
Entity Type:Organization
Organization Name:FISHOMEN P.C.
Other - Org Name:IOWA CENTER FOR COSMETIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHELAN
Authorized Official - Middle Name:RICO
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-223-8800
Mailing Address - Street 1:4100 UNIVERSITY AVE
Mailing Address - Street 2:#105
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5956
Mailing Address - Country:US
Mailing Address - Phone:515-223-8800
Mailing Address - Fax:515-223-1437
Practice Address - Street 1:4100 UNIVERSITY AVE
Practice Address - Street 2:#105
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5956
Practice Address - Country:US
Practice Address - Phone:515-223-8800
Practice Address - Fax:515-223-1437
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
IA071981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty