Healthcare Provider Details

I. General information

NPI: 1508482852
Provider Name (Legal Business Name): ELITE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 EDGEWOOD ROAD NW
CEDAR RAPIDS IA
52405-4472
US

IV. Provider business mailing address

222 EDGEWOOD ROAD NW
CEDAR RAPIDS IA
52405-4472
US

V. Phone/Fax

Practice location:
  • Phone: 319-396-8364
  • Fax: 319-396-5800
Mailing address:
  • Phone: 319-396-8364
  • Fax: 319-396-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. BRADY ALLEN NOVAK
Title or Position: ORTHODENTIST CO-OWNER
Credential: DDS, MS
Phone: 319-396-8364