1164761698 NPI number — DIAMOND TRAIL DENTAL PC

Table of content: (NPI 1164761698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164761698 NPI number — DIAMOND TRAIL DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMOND TRAIL DENTAL PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DIAMOND TRAIL DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164761698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 HIGH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSKALOOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52577-2831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-673-3008
Provider Business Mailing Address Fax Number:
641-672-8807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S. 4TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEZUMA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50171-1031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-623-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEBOEF
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
CHAD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
641-673-3008

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)