MEDICARE: SB IOWA DENTISTRY PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1215439567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SB IOWA DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 70887
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44190-0887
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2953 5TH AVE S
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2923
Country	:	US
Telephone Number	:	515-576-6656
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHACHINDRA BAHADUR
Credential	:
Telephone Number	:	515-576-6656

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	06/21/2023

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