MEDICARE: PEDIATRIC DENTISTRY OF CENTRAL IOWA, P.C.

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	1223P0221X	Pediatric Dentistry		IA

General Provider Information

NPI Number	:	1275618886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY OF CENTRAL IOWA, P.C.

Provider Business Mailing Address
First Line	:	1000 73RD ST
Second Line	:	SUITE 10
City	:	DES MOINES
State	:	IA
Zip	:	50324-1321
Country	:	US
Telephone Number	:	515-223-1298
Fax Number	:	515-223-1959

Provider Business Practice Location Address
First Line	:	1000 73RD ST
Second Line	:	SUITE 10
City	:	DES MOINES
State	:	IA
Zip	:	50324-1321
Country	:	US
Telephone Number	:	515-223-1298
Fax Number	:	515-223-1959

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VINCENT W. MANCUSO JR.
Credential	:	D.D.S.
Telephone Number	:	515-223-1298

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/12/2010

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