MEDICARE: GENTLE FAMILY DENTISTS

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	6899	IA

General Provider Information

NPI Number	:	1932376191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENTLE FAMILY DENTISTS

Provider Business Mailing Address
First Line	:	1205 N COLUMBUS ST
Second Line	:
City	:	WEST LIBERTY
State	:	IA
Zip	:	52776-9601
Country	:	US
Telephone Number	:	319-627-2612
Fax Number	:	319-627-2178

Provider Business Practice Location Address
First Line	:	1205 N COLUMBUS ST
Second Line	:
City	:	WEST LIBERTY
State	:	IA
Zip	:	52776-9601
Country	:	US
Telephone Number	:	319-627-2612
Fax Number	:	319-627-2178

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CAROL L MORENO
Credential	:	DDS
Telephone Number	:	319-627-2612

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	01/09/2013

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