=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376303438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THROCKMORTON DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2024
-----------------------------------------------------
Last Update Date | 03/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 NW 36TH ST STE 400
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-8445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-790-6465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3003 NW MAPLE CT
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-7931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-790-7733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS, OWNER
-----------------------------------------------------
Name | BRANDON A THROCKMORTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 712-790-6465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------