Provider Demographics
NPI:1427079201
Name:CENTRAL PARK DENTISTRY
Entity type:Organization
Organization Name:CENTRAL PARK DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-423-4225
Mailing Address - Street 1:23 N FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3250
Mailing Address - Country:US
Mailing Address - Phone:641-423-4225
Mailing Address - Fax:641-423-1697
Practice Address - Street 1:23 N FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3250
Practice Address - Country:US
Practice Address - Phone:641-423-4225
Practice Address - Fax:641-423-1697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0094094Medicaid