NPI |
1629586433 |
The date that a record was last updated or changed. |
Entity Type Code |
2 |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Employer Identification Number EIN |
|
The first name of the authorized official. |
Provider Organization Name Legal Business Name |
ASPEN DENTAL POP WEST DES MOINES PC |
The title or position of the authorized official. |
Provider First Line Business Practice Location Address |
6630 MILLS CIVIC PKWY UNIT 1110 |
The 10-position telephone number of the authorized official. |
Provider Business Practice Location Address City Name |
WEST DES MOINES |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Business Practice Location Address State Name |
IA |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Business Practice Location Address Postal Code |
502668354 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Business Practice Location Address Country Code If outside U S |
US |
|
Provider Business Practice Location Address Telephone Number |
5153277000 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Provider Enumeration Date |
1/15/2018 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Last Update Date |
1/15/2018 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
TESENE |
|
Authorized Official First Name |
JOSEPH |
|
Authorized Official Title or Position |
OWNER |
The title or position of the authorized official. |
Authorized Official Telephone Number |
5153277000 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
1223G0001X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Healthcare Provider Taxonomy Group 1 |
193400000X MULTIPLE SINGLE SPECIALTY GROUP |
|