=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619852423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGDOM DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2025
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 12TH ST
-----------------------------------------------------
City | BELLE PLAINE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52208-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-444-3343
-----------------------------------------------------
Fax | 319-444-2607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 12TH ST
-----------------------------------------------------
City | BELLE PLAINE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52208-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-444-3343
-----------------------------------------------------
Fax | 319-444-2607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DANIEL DUROSEAU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 951-204-3651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------