Provider Demographics
NPI:1811283302
Name:LEGACY DENTAL, P.C.
Entity type:Organization
Organization Name:LEGACY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PURK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-285-8888
Mailing Address - Street 1:4409 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-3909
Mailing Address - Country:US
Mailing Address - Phone:515-285-8888
Mailing Address - Fax:515-287-7760
Practice Address - Street 1:4409 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-3909
Practice Address - Country:US
Practice Address - Phone:515-285-8888
Practice Address - Fax:515-287-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7566261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1083827117Medicaid