Healthcare Provider Details

I. General information

NPI: 1871569459
Provider Name (Legal Business Name): RICHARD K BOKEMPER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 FIRST ST
SERGEANT BLUFF IA
51054
US

IV. Provider business mailing address

PO BOX 280 703 FIRST ST
SERGEANT BLUFF IA
51054
US

V. Phone/Fax

Practice location:
  • Phone: 712-943-4242
  • Fax: 712-943-4243
Mailing address:
  • Phone: 712-943-4242
  • Fax: 712-943-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7009
License Number StateIA

VII. Legacy identifiers

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

# 1
IdentifierIA217992
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier4212770114
Identifier TypeOTHER
Identifier StateNE
Identifier IssuerMEDICAID NEBRASKA

VIII. Authorized Official

Name: DR. RICHARD KEITH BOKEMPER
Title or Position: PRESIDENT OWNER
Credential: DDS
Phone: 712-943-4242