Healthcare Provider Details

I. General information

NPI: 1417867946
Provider Name (Legal Business Name): SHADOW CREEK PEDIATRIC DENTISTRY OF WAUKEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 NE ALICES RD
WAUKEE IA
50263-8857
US

IV. Provider business mailing address

822 NE ALICES RD
WAUKEE IA
50263-8857
US

V. Phone/Fax

Practice location:
  • Phone: 515-264-2772
  • Fax:
Mailing address:
  • Phone: 515-264-2772
  • 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: MR. LUCAS BLAND
Title or Position: COO
Credential:
Phone: 515-577-6367