1992962732 NPI number — EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY

Table of content: (NPI 1992962732)

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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