Provider Demographics
NPI:1699981233
Name:CEDAR VALLEY DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:CEDAR VALLEY DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-266-7559
Mailing Address - Street 1:3722 CEDAR HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-6207
Mailing Address - Country:US
Mailing Address - Phone:319-266-7559
Mailing Address - Fax:
Practice Address - Street 1:3722 CEDAR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613
Practice Address - Country:US
Practice Address - Phone:319-266-7559
Practice Address - Fax:319-277-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA62081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0143206Medicaid