Healthcare Provider Details

I. General information

NPI: 1295902161
Provider Name (Legal Business Name): JERRY W. KAALBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2008
Last Update Date: 05/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 319-364-7111
  • Fax:
Mailing address:
  • Phone: 319-364-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5773
License Number StateIA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: