Provider Demographics
NPI:1538719075
Name:INDIANOLA PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:INDIANOLA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-808-7000
Mailing Address - Street 1:2001 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-4873
Mailing Address - Country:US
Mailing Address - Phone:515-808-7000
Mailing Address - Fax:515-808-7001
Practice Address - Street 1:2001 N 6TH ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-4873
Practice Address - Country:US
Practice Address - Phone:319-283-0284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty