Provider Demographics
NPI:1386067817
Name:SPRING PARK ORAL AND MAXILLOFACIAL SURGEONS, P.C.
Entity type:Organization
Organization Name:SPRING PARK ORAL AND MAXILLOFACIAL SURGEONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-359-1601
Mailing Address - Street 1:5345 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2764
Mailing Address - Country:US
Mailing Address - Phone:563-359-1601
Mailing Address - Fax:563-355-7111
Practice Address - Street 1:1111 CANAL SHORE DR SW
Practice Address - Street 2:
Practice Address - City:LE CLAIRE
Practice Address - State:IA
Practice Address - Zip Code:52753-7602
Practice Address - Country:US
Practice Address - Phone:563-355-1034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA8664261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA87346Medicaid
IA8734Medicare PIN