Healthcare Provider Details

I. General information

NPI: 1235360975
Provider Name (Legal Business Name): WESTDALE DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 WILSON AVE SW
CEDAR RAPIDS IA
52404-6342
US

IV. Provider business mailing address

4135 WILSON AVE SW
CEDAR RAPIDS IA
52404-6342
US

V. Phone/Fax

Practice location:
  • Phone: 319-396-0700
  • Fax: 319-396-4410
Mailing address:
  • Phone: 319-396-0700
  • Fax: 319-396-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08112
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6700
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. MICHAEL S THOMAS
Title or Position: OWNER
Credential: DDS
Phone: 319-396-0700