Provider Demographics
NPI:1982769386
Name:MAIN FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:MAIN FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:RAYMNOD
Authorized Official - Last Name:GRIEBAHN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-323-2571
Mailing Address - Street 1:1905 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2908
Mailing Address - Country:US
Mailing Address - Phone:563-323-2571
Mailing Address - Fax:563-323-1069
Practice Address - Street 1:1905 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2908
Practice Address - Country:US
Practice Address - Phone:563-323-2571
Practice Address - Fax:563-323-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6943261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0431924Medicaid