Healthcare Provider Details

I. General information

NPI: 1558139170
Provider Name (Legal Business Name): CHILDRENS DENTAL COUNCIL BLUFFS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 MADISON AVE STE 3
COUNCIL BLUFFS IA
51503-5200
US

IV. Provider business mailing address

1860 MADISON AVE STE 3
COUNCIL BLUFFS IA
51503-5200
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-9263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN MARIE MYERS
Title or Position: INSURANCE MANAGER
Credential:
Phone: 402-932-9263