Provider Demographics
NPI:1780771196
Name:THE NETTLETON DENTAL GROUP, PC
Entity type:Organization
Organization Name:THE NETTLETON DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DONOVAN
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-424-4521
Mailing Address - Street 1:946 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-4202
Mailing Address - Country:US
Mailing Address - Phone:641-424-4521
Mailing Address - Fax:641-424-8403
Practice Address - Street 1:946 E STATE ST
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-4202
Practice Address - Country:US
Practice Address - Phone:641-424-4521
Practice Address - Fax:641-424-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1604972OtherUNITED CONCORDIA
IA0248898Medicaid