Healthcare Provider Details

I. General information

NPI: 1346377918
Provider Name (Legal Business Name): THE CEDAR RAPIDS DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 38TH ST SE
CEDAR RAPIDS IA
52403-4300
US

IV. Provider business mailing address

815 38TH ST SE
CEDAR RAPIDS IA
52403-4300
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-0534
  • Fax: 319-297-7417
Mailing address:
  • Phone: 319-365-0534
  • Fax: 319-297-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7446
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7949
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7446
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7588
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0280362
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier0281063
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 3
Identifier0084855
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MS. LISA M SHANNON
Title or Position: OFFICE MANAGER
Credential:
Phone: 319-365-0534