Provider Demographics
NPI:1154701316
Name:LIFEPOINT IV DENTAL GROUP LLC
Entity type:Organization
Organization Name:LIFEPOINT IV DENTAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-965-1800
Mailing Address - Street 1:3311 SW 9TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-7677
Mailing Address - Country:US
Mailing Address - Phone:515-243-7641
Mailing Address - Fax:888-278-0530
Practice Address - Street 1:110 SE GRANT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-3151
Practice Address - Country:US
Practice Address - Phone:515-965-1800
Practice Address - Fax:888-278-0530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEPOINT DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty