Provider Demographics
NPI:1043755408
Name:CEDAR RAPIDS PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:CEDAR RAPIDS PEDIATRIC DENTISTRY LLC
Other - Org Name:CEDAR RAPIDS PEDIATRIC DENTISTRY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-364-2413
Mailing Address - Street 1:1962 1ST AVE NE
Mailing Address - Street 2:CEDAR RAPIDS PEDIATRIC DENTISTRY
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5330
Mailing Address - Country:US
Mailing Address - Phone:319-364-2413
Mailing Address - Fax:
Practice Address - Street 1:1962 1ST AVE NE
Practice Address - Street 2:CEDAR RAPIDS PEDIATRIC DENTISTRY
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5330
Practice Address - Country:US
Practice Address - Phone:319-364-2413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087951223P0221X
IA087651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty