=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437339355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILEDENTAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 11/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 E AGENCY RD STE 11
-----------------------------------------------------
City | WEST BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52655-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-754-1527
-----------------------------------------------------
Fax | 319-758-0407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 E AGENCY RD STE 11
-----------------------------------------------------
City | WEST BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52655-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-754-1527
-----------------------------------------------------
Fax | 319-758-0407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD JOHN TAEGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 319-754-1527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------