Provider Demographics
NPI:1588082739
Name:DENTISTRY ON 5TH
Entity type:Organization
Organization Name:DENTISTRY ON 5TH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEANN
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:SOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-243-4616
Mailing Address - Street 1:505 5TH AVE
Mailing Address - Street 2:SUITE 939
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-2324
Mailing Address - Country:US
Mailing Address - Phone:515-243-4616
Mailing Address - Fax:
Practice Address - Street 1:505 5TH AVE
Practice Address - Street 2:SUITE 939
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-2324
Practice Address - Country:US
Practice Address - Phone:515-243-4616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089501223G0001X
IA084541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty