Healthcare Provider Details

I. General information

NPI: 1700874617
Provider Name (Legal Business Name): DEBRA K. OLDHAM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W MAIN ST
ANAMOSA IA
52205-1636
US

IV. Provider business mailing address

702 W MAIN ST
ANAMOSA IA
52205-1636
US

V. Phone/Fax

Practice location:
  • Phone: 319-462-2531
  • Fax: 319-462-2914
Mailing address:
  • Phone: 319-462-2531
  • Fax: 319-462-2914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7608
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: