Healthcare Provider Details

I. General information

NPI: 1538226055
Provider Name (Legal Business Name): MISSOURI VALLEY DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E ERIE ST
MISSOURI VALLEY IA
51555-1533
US

IV. Provider business mailing address

214 E ERIE ST
MISSOURI VALLEY IA
51555-1533
US

V. Phone/Fax

Practice location:
  • Phone: 712-642-4136
  • Fax: 712-642-3491
Mailing address:
  • Phone: 712-642-4136
  • Fax: 712-642-3491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. JEAN ANN KERGER
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 712-642-4136