1700105442 NPI number — CEDAR VALLEY ENDODONTICS, LLC

Table of content: (NPI 1700105442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700105442 NPI number — CEDAR VALLEY ENDODONTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR VALLEY ENDODONTICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700105442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 BROOKERIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50702-5703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-233-0803
Provider Business Mailing Address Fax Number:
319-233-1945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 BROOKERIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50702-5703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-233-0803
Provider Business Practice Location Address Fax Number:
319-233-1945
Provider Enumeration Date:
05/20/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WINGROVE
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
PAIGE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
319-233-0803

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  08295 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)