Provider Demographics
NPI:1205093903
Name:MOFFITT DENTAL CENTER
Entity type:Organization
Organization Name:MOFFITT DENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:MOFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-448-4852
Mailing Address - Street 1:422 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1704
Mailing Address - Country:US
Mailing Address - Phone:515-448-4852
Mailing Address - Fax:515-448-3533
Practice Address - Street 1:422 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-1704
Practice Address - Country:US
Practice Address - Phone:515-448-4852
Practice Address - Fax:515-448-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6102261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0148007Medicaid
IA010720525OtherAMERICAN DENTAL ASSOCIATION
IA1613OtherAMERICAN COLLEGE OF PROSTHODONTICS
IA14800OtherWELLMARK BLUE CROSS/BLUE SHIELD