Healthcare Provider Details

I. General information

NPI: 1841231644
Provider Name (Legal Business Name): FAMILY SMILECARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 32ND ST NE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

1630 32ND ST NE
CEDAR RAPIDS IA
52402
US

V. Phone/Fax

Practice location:
  • Phone: 319-362-8657
  • Fax: 319-362-1824
Mailing address:
  • Phone: 319-362-8657
  • Fax: 319-362-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7308
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4870
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08065
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number07308
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0247759
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier55943
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name: DR. RENEE ELAINE MAIKON
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 319-362-8657