Provider Demographics
NPI:1720478878
Name:STATER DENTAL
Entity Type:Organization
Organization Name:STATER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:STATER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:641-856-8643
Mailing Address - Street 1:112 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1730
Mailing Address - Country:US
Mailing Address - Phone:641-856-8643
Mailing Address - Fax:
Practice Address - Street 1:112 N 10TH ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1730
Practice Address - Country:US
Practice Address - Phone:641-856-8643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-06366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1821160755Medicaid