Healthcare Provider Details

I. General information

NPI: 1528135944
Provider Name (Legal Business Name): CONTEMPORARY PERIODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 RIVER RIDGE DRIVE NE SUITE A
CEDAR RAPIDS IA
52402-7599
US

IV. Provider business mailing address

3900 RIVER RIDGE DRIVE NE SUITE A
CEDAR RAPIDS IA
52402-7599
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-9880
  • Fax: 319-363-8386
Mailing address:
  • Phone: 319-363-9880
  • Fax: 319-363-8386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7959
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier00980081
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED CONCORDIA
# 2
Identifier46932
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BCBS

VIII. Authorized Official

Name: DR. TRUMAN CHRISTOPHER JOHNSON
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 319-363-9880