1992962732 NPI number — EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992962732 NPI number — EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY
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:
1992962732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4150 EDGEWOOD ROAD NE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52402-0609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-366-8277
Provider Business Mailing Address Fax Number:
319-366-7091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4150 EDGEWOOD ROAD NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402-0609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-366-8277
Provider Business Practice Location Address Fax Number:
319-366-7091
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
319-366-8277

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  08986 , 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)

  • Identifier: 08986 . This is a "BENJAMIN L. FULLER LICENSE NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1265727150 . This is a "JAROM E. MAURER NPI" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1689802910 . This is a "BENJAMIN L. FULLER NPI" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 09173 . This is a "JAROM E. MAURER LICENSE NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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