Provider Demographics
NPI:1104036755
Name:OLYMPIC DENTISTRY, PLC
Entity Type:Organization
Organization Name:OLYMPIC DENTISTRY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LUDENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-234-3233
Mailing Address - Street 1:208 OLYMPIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-5240
Mailing Address - Country:US
Mailing Address - Phone:319-234-3233
Mailing Address - Fax:319-234-3879
Practice Address - Street 1:208 OLYMPIC DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5240
Practice Address - Country:US
Practice Address - Phone:319-234-3233
Practice Address - Fax:319-234-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07466261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental