Healthcare Provider Details

I. General information

NPI: 1841324084
Provider Name (Legal Business Name): FORT DODGE ORAL AND MAXILLOFACIAL SURGERY LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 KENYON RD STE 120
FORT DODGE IA
50501-5742
US

IV. Provider business mailing address

804 KENYON RD STE 120
FORT DODGE IA
50501-5746
US

V. Phone/Fax

Practice location:
  • Phone: 515-576-8727
  • Fax: 515-576-7076
Mailing address:
  • Phone: 515-576-8727
  • Fax: 515-576-7076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIA

VIII. Authorized Official

Name: ELIZABETH SCHRAUTH
Title or Position: OFFICE MANAGER
Credential:
Phone: 515-576-8727