Healthcare Provider Details

I. General information

NPI: 1043755408
Provider Name (Legal Business Name): CEDAR RAPIDS PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 1ST AVE NE CEDAR RAPIDS PEDIATRIC DENTISTRY
CEDAR RAPIDS IA
52402-5330
US

IV. Provider business mailing address

1962 1ST AVE NE CEDAR RAPIDS PEDIATRIC DENTISTRY
CEDAR RAPIDS IA
52402-5330
US

V. Phone/Fax

Practice location:
  • Phone: 319-364-2413
  • Fax:
Mailing address:
  • Phone: 319-364-2413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number08765
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number08795
License Number StateIA

VIII. Authorized Official

Name: SARAH E SWENSON
Title or Position: MANAGER
Credential: DDS
Phone: 319-364-2413