MEDICARE: J&M SUNNYBROOK INC DBA SUNNYBROOK DENTAL

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	261QD0000X	Dental Clinic/Center	08173	IA

General Provider Information

NPI Number	:	1669660254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J&M SUNNYBROOK INC DBA SUNNYBROOK DENTAL

Provider Business Mailing Address
First Line	:	5708 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4249
Country	:	US
Telephone Number	:	712-274-2338
Fax Number	:

Provider Business Practice Location Address
First Line	:	5708 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4249
Country	:	US
Telephone Number	:	712-274-2338
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. MINDY J. STEVENS
Credential	:	DDS
Telephone Number	:	712-274-2338

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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