=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275504177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORAL SURGEONS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3940 INGERSOLL AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50312-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-274-9151
-----------------------------------------------------
Fax | 515-274-1472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3940 INGERSOLL AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50312-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-274-9151
-----------------------------------------------------
Fax | 515-274-1472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARVIN C JEPSEN
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 515-274-9151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------