Healthcare Provider Details

I. General information

NPI: 1134248578
Provider Name (Legal Business Name): CEDAR RAPIDS ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 1ST AVE NE STE 410
CEDAR RAPIDS IA
52402-4845
US

IV. Provider business mailing address

2750 1ST AVE NE STE 410
CEDAR RAPIDS IA
52402-4845
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-1456
  • Fax: 319-261-0118
Mailing address:
  • Phone: 319-365-1456
  • Fax: 319-261-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number08090
License Number StateIA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. JACK C LIU
Title or Position: PRESIDENT ENDODONTIST
Credential: DDS, PHD
Phone: 319-365-1456