Healthcare Provider Details

I. General information

NPI: 1043871411
Provider Name (Legal Business Name): CEDAR RAPIDS PERIODONTICS & DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 02/15/2020
Certification Date: 02/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 1ST AVE SE STE 3
CEDAR RAPIDS IA
52402-4844
US

IV. Provider business mailing address

2727 1ST AVE SE STE 3
CEDAR RAPIDS IA
52402-4844
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-6150
  • Fax:
Mailing address:
  • Phone: 319-365-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH BALLATORE
Title or Position: PRESIDENT
Credential: DMD
Phone: 319-365-6150