MEDICARE: DES MOINES DENTAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1205907896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DES MOINES DENTAL GROUP

Provider Business Mailing Address
First Line	:	8515 DOUGLAS AVE
Second Line	:	SUITE 21
City	:	DES MOINES
State	:	IA
Zip	:	50322-2924
Country	:	US
Telephone Number	:	515-278-2361
Fax Number	:	515-276-9233

Provider Business Practice Location Address
First Line	:	8515 DOUGLAS AVE
Second Line	:	SUITE 21
City	:	DES MOINES
State	:	IA
Zip	:	50322-2924
Country	:	US
Telephone Number	:	515-278-2361
Fax Number	:	515-276-9233

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. JEFF BRANDT
Credential	:
Telephone Number	:	515-278-2361

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	03/09/2009

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