Healthcare Provider Details

I. General information

NPI: 1245376847
Provider Name (Legal Business Name): WILLIAM H OLIN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 1ST AVENUE NE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

2720 1ST AVENUE NE
CEDAR RAPIDS IA
52402
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-6628
  • Fax: 319-896-4747
Mailing address:
  • Phone: 319-365-6628
  • Fax: 319-896-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number06572
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0005413
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: