=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982781340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN IOWA ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2635 LINCOLN WAY STE E
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52732-7229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-243-6622
-----------------------------------------------------
Fax | 563-242-1484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2635 LINCOLN WAY STE E
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52732-7229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-243-6622
-----------------------------------------------------
Fax | 563-242-1484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JENNIFER TUCKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-243-6622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 07343
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------