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General NPI Number Information
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NPI Number | 1982769386
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Entity Type | Organization
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Legal Business Name | MAIN FAMILY DENTAL CARE
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Dates
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Enumeration Date | 12/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1905 N MAIN ST
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City | DAVENPORT
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State | IA
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Zip | 52803-2908
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Country | US
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Telephone | 563-323-2571
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Fax | 563-323-1069
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Provider Business Mailing Address
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Address Line | 1905 N MAIN ST
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City | DAVENPORT
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State | IA
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Zip | 52803-2908
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Country | US
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Telephone | 563-323-2571
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Fax | 563-323-1069
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LYNN RAYMNOD GRIEBAHN JR.
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Credential | DDS
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Telephone | 563-323-2571
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6943
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License Number State | IA
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