Healthcare Provider Details

I. General information

NPI: 1306407226
Provider Name (Legal Business Name): MAYTHAM FALAH QAISI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 EDGEWOOD RD SW UNIT 160
CEDAR RAPIDS IA
52404
US

IV. Provider business mailing address

2315 EDGEWOOD RD SW UNIT 160
CEDAR RAPIDS IA
52404-3391
US

V. Phone/Fax

Practice location:
  • Phone: 319-390-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-09692
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: