Provider Demographics
NPI:1538828678
Name:INGERSOLL FAMILY DENTISTRY
Entity type:Organization
Organization Name:INGERSOLL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:GRADOVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-243-2412
Mailing Address - Street 1:2800 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4013
Mailing Address - Country:US
Mailing Address - Phone:515-243-2412
Mailing Address - Fax:
Practice Address - Street 1:2800 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4013
Practice Address - Country:US
Practice Address - Phone:515-243-2412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty