Healthcare Provider Details

I. General information

NPI: 1609030246
Provider Name (Legal Business Name): DOUGLAS J HORTON DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 GLASS ROAD NE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

4141 GLASS ROAD NE
CEDAR RAPIDS IA
52402
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-0773
  • Fax: 319-294-4423
Mailing address:
  • Phone: 319-393-0773
  • Fax: 319-294-4423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6174
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0137794
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DR. DOUGLAS J HORTON
Title or Position: OWNER
Credential: DDS
Phone: 319-393-0773