=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184938755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAWKEYE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2010
-----------------------------------------------------
Last Update Date | 06/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 S 1ST AVE STE P
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52240-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-338-7172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 N 2ND ST
-----------------------------------------------------
City | WAPELLO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52653-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-527-6421
-----------------------------------------------------
Fax | 319-527-6422
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | ROCKY LEROY HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 319-338-7172
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 08287
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------