Provider Demographics
NPI:1043532302
Name:CORNERSTONE DENTAL OF IOWA,LLC
Entity type:Organization
Organization Name:CORNERSTONE DENTAL OF IOWA,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRPERSON
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-984-6001
Mailing Address - Street 1:PO BOX 170
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-0170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N 3RD STREET
Practice Address - Street 2:UNIT F
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226
Practice Address - Country:US
Practice Address - Phone:515-984-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0080200Medicaid