MEDICARE: EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	08986	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08986	OTHER	IA	BENJAMIN L. FULLER LICENSE NUMBER
2	1265727150	OTHER	IA	JAROM E. MAURER NPI
3	1689802910	OTHER	IA	BENJAMIN L. FULLER NPI
4	09173	OTHER	IA	JAROM E. MAURER LICENSE NUMBER

General Provider Information

NPI Number	:	1992962732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY

Provider Business Mailing Address
First Line	:	4150 EDGEWOOD ROAD NE
Second Line	:	SUITE 100
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52402-0609
Country	:	US
Telephone Number	:	319-366-8277
Fax Number	:	319-366-7091

Provider Business Practice Location Address
First Line	:	4150 EDGEWOOD ROAD NE
Second Line	:	SUITE 100
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52402-0609
Country	:	US
Telephone Number	:	319-366-8277
Fax Number	:	319-366-7091

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SUZANNE J. STEWART
Credential	:
Telephone Number	:	319-366-8277

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	12/28/2021

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Directions to “EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY ” Practice Location

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