MEDICARE: THE CHILDREN'S DENTAL CENTER, 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1528681897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHILDREN'S DENTAL CENTER, PLLC

Provider Business Mailing Address
First Line	:	2761 OAKDALE BLVD STE 4
Second Line	:
City	:	CORALVILLE
State	:	IA
Zip	:	52241-9754
Country	:	US
Telephone Number	:	319-626-5437
Fax Number	:	319-626-2301

Provider Business Practice Location Address
First Line	:	2761 OAKDALE BLVD STE 4
Second Line	:
City	:	CORALVILLE
State	:	IA
Zip	:	52241-9754
Country	:	US
Telephone Number	:	319-626-5437
Fax Number	:	319-626-2301

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JODIE HARGROVE
Credential	:
Telephone Number	:	319-626-5437

Provider Enumeration Date	:	05/21/2020
Last Update Date	:	05/21/2020

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