Provider Demographics
NPI:1245656800
Name:IOWA PEDIATRIC DENTAL CENTER II LLC
Entity type:Organization
Organization Name:IOWA PEDIATRIC DENTAL CENTER II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-366-0600
Mailing Address - Street 1:5350 KIRKWOOD BLVD SW
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-5233
Mailing Address - Country:US
Mailing Address - Phone:319-366-0600
Mailing Address - Fax:319-366-1316
Practice Address - Street 1:5350 KIRKWOOD BLVD SW
Practice Address - Street 2:SUITE 700
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-5233
Practice Address - Country:US
Practice Address - Phone:319-366-0600
Practice Address - Fax:319-366-1316
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IOWA PEDIATRIC DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty