Healthcare Provider Details

I. General information

NPI: 1205093903
Provider Name (Legal Business Name): MOFFITT DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 W BROADWAY ST
EAGLE GROVE IA
50533-1704
US

IV. Provider business mailing address

422 W BROADWAY ST
EAGLE GROVE IA
50533-1704
US

V. Phone/Fax

Practice location:
  • Phone: 515-448-4852
  • Fax: 515-448-3533
Mailing address:
  • Phone: 515-448-4852
  • Fax: 515-448-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6102
License Number StateIA

VIII. Authorized Official

Name: DR. MICHAEL WALTER MOFFITT
Title or Position: OWNER/DOCTOR
Credential: DDS
Phone: 515-448-4852