Provider Demographics
NPI:1912161944
Name:FAMILY FIRST DENTAL OF PRIMGHAR, P.C.
Entity Type:Organization
Organization Name:FAMILY FIRST DENTAL OF PRIMGHAR, P.C.
Other - Org Name:FAMILY 1ST DENTAL OF LAKE CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:SKOGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-644-3177
Mailing Address - Street 1:1331 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-1585
Mailing Address - Country:US
Mailing Address - Phone:712-464-3124
Mailing Address - Fax:
Practice Address - Street 1:1331 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1585
Practice Address - Country:US
Practice Address - Phone:712-464-3124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0265447Medicaid
IA55729OtherWELLMARK
NE10025042400Medicaid