1659934701 NPI number — GRIMES PEDIATRIC DENTISTRY P C

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 1659934701 NPI number — GRIMES PEDIATRIC DENTISTRY P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRIMES PEDIATRIC DENTISTRY P C
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:
1659934701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 MAIN ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52001-7654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-582-1448
Provider Business Mailing Address Fax Number:
563-726-7070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 SE 3RD ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRIMES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50111-8861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-325-1719
Provider Business Practice Location Address Fax Number:
515-373-4883
Provider Enumeration Date:
04/15/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MONTES
Authorized Official First Name:
EMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
CBO MANAGER
Authorized Official Telephone Number:
563-552-0053

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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