Healthcare Provider Details

I. General information

NPI: 1861502437
Provider Name (Legal Business Name): KELLEY JO RUEHS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W 1ST ST
CEDAR FALLS IA
50613-2113
US

IV. Provider business mailing address

1301 W 1ST ST
CEDAR FALLS IA
50613-2113
US

V. Phone/Fax

Practice location:
  • Phone: 319-277-4600
  • Fax: 319-266-5270
Mailing address:
  • Phone: 319-277-4600
  • Fax: 319-266-5270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number07938
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1178137
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: