Healthcare Provider Details

I. General information

NPI: 1700395365
Provider Name (Legal Business Name): DENTISTRY FOR CHILDREN OF IOWA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 128TH ST
URBANDALE IA
50323-1816
US

IV. Provider business mailing address

1350 SPRING ST NW STE 600
ATLANTA GA
30309-2870
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TAMONIA LEONARD
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 678-244-4844