Healthcare Provider Details

I. General information

NPI: 1154328201
Provider Name (Legal Business Name): MARVIN KIRK FREEBURG D,D,S,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 LYNN AVE SUITE 109
AMES IA
50014-7126
US

IV. Provider business mailing address

4010 STONE BROOKE RD
AMES IA
50010-2900
US

V. Phone/Fax

Practice location:
  • Phone: 515-292-7262
  • Fax: 515-292-7270
Mailing address:
  • Phone: 515-232-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5891
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: