=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578763090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAKDALE DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2007
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2441 CORAL CT STE 5
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-545-6251
-----------------------------------------------------
Fax | 319-545-7265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2441 CORAL CT STE 5
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-545-6251
-----------------------------------------------------
Fax | 319-545-7265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHAD R HANNEMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 319-545-6251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8001
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------