=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467834010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HINTZ FAMILY DENTISTRY MARSHALLTOWN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2015
-----------------------------------------------------
Last Update Date | 06/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 E SOUTHRIDGE RD
-----------------------------------------------------
City | MARSHALLTOWN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50158-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-753-1374
-----------------------------------------------------
Fax | 641-751-1193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 E SOUTHRIDGE RD
-----------------------------------------------------
City | MARSHALLTOWN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50158-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-753-1374
-----------------------------------------------------
Fax | 641-751-1193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JERAD L HINTZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 641-753-1374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 08568
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------