Provider Demographics
NPI:1861106700
Name:SOUTH DES MOINES DENTAL
Entity type:Organization
Organization Name:SOUTH DES MOINES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-285-9962
Mailing Address - Street 1:4401 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-3909
Mailing Address - Country:US
Mailing Address - Phone:515-285-9962
Mailing Address - Fax:515-285-9699
Practice Address - Street 1:4401 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-3909
Practice Address - Country:US
Practice Address - Phone:515-285-9962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental