=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083947667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN IOWA PERIODONTICS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2009
-----------------------------------------------------
Last Update Date | 09/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 12TH AVE SUITE 202
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-1774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-351-5439
-----------------------------------------------------
Fax | 319-354-0491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 12TH AVE SUITE 202
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-1774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-351-5439
-----------------------------------------------------
Fax | 319-354-0491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. ADRIENNE S GUNSTREAM
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 319-351-5439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 08614
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------