Provider Demographics
NPI:1194784389
Name:SPRING PARK ORAL AND MAXILLOFACIAL SURGEONS
Entity type:Organization
Organization Name:SPRING PARK ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TESHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-359-1601
Mailing Address - Street 1:407 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4512
Mailing Address - Country:US
Mailing Address - Phone:563-243-4406
Mailing Address - Fax:563-243-8534
Practice Address - Street 1:407 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4512
Practice Address - Country:US
Practice Address - Phone:563-243-4406
Practice Address - Fax:563-243-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty