Provider Demographics
NPI:1538240924
Name:PRAHL, JERRY CURTIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CURTIS
Last Name:PRAHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 HAMILTON BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-255-7607
Mailing Address - Fax:712-255-4507
Practice Address - Street 1:2928 HAMILTON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-255-7607
Practice Address - Fax:712-255-4507
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05181122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0116285Medicaid