Provider Demographics
NPI:1720173990
Name:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Other - Org Name:WAUKON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-568-4528
Mailing Address - Street 1:18 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172
Mailing Address - Country:US
Mailing Address - Phone:563-568-4528
Mailing Address - Fax:563-568-6144
Practice Address - Street 1:18 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172
Practice Address - Country:US
Practice Address - Phone:563-568-4528
Practice Address - Fax:563-568-6144
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST IOWA DENTAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty