Healthcare Provider Details

I. General information

NPI: 1730355033
Provider Name (Legal Business Name): CLINTON DENTAL SURGERY CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 N 2ND ST
CLINTON IA
52732-2434
US

IV. Provider business mailing address

2314 N 2ND ST
CLINTON IA
52732-2434
US

V. Phone/Fax

Practice location:
  • Phone: 563-242-1565
  • Fax: 563-242-0095
Mailing address:
  • Phone: 563-242-1565
  • Fax: 563-242-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number06659
License Number StateIA

VIII. Authorized Official

Name: DR. ROBERT M ALT
Title or Position: CORPORATE V.P. AND SEC
Credential: DDS
Phone: 563-242-1565