Healthcare Provider Details

I. General information

NPI: 1104036755
Provider Name (Legal Business Name): OLYMPIC DENTISTRY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 OLYMPIC DR
WATERLOO IA
50701-5240
US

IV. Provider business mailing address

208 OLYMPIC DRIVE
WATERLOO IA
50701-5240
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-3233
  • Fax: 319-234-3879
Mailing address:
  • Phone: 319-234-3233
  • Fax: 319-234-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number07466
License Number StateIA

VIII. Authorized Official

Name: DR. BRENT EUGENE LUDENS
Title or Position: OWNER
Credential: D.D.S.
Phone: 319-234-3233