Healthcare Provider Details

I. General information

NPI: 1710390125
Provider Name (Legal Business Name): CARLA KUCIREK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLA GROSSKLAUS

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E SUMMIT ST
RED OAK IA
51566-1711
US

IV. Provider business mailing address

1700 E SUMMIT ST
RED OAK IA
51566-1711
US

V. Phone/Fax

Practice location:
  • Phone: 712-623-5404
  • Fax: 712-623-5404
Mailing address:
  • Phone: 712-623-5404
  • Fax: 712-623-5231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-09081
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number09081
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: