1336485424 NPI number — PRAIRIE TRAILS FAMILY DENTAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336485424 NPI number — PRAIRIE TRAILS FAMILY DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE TRAILS FAMILY DENTAL LLC
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:
Provider Other Organization Name Type Code:
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:
1336485424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORYDON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50060-0284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-872-2514
Provider Business Mailing Address Fax Number:
641-872-1152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORYDON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50060-1724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-872-2514
Provider Business Practice Location Address Fax Number:
641-872-1152
Provider Enumeration Date:
12/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR. ADMINISTRATIVE SERVICES
Authorized Official Telephone Number:
641-872-5341

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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