Provider Demographics
NPI:1225468812
Name:KAREN POTACZEK, D.D.S., P.C.
Entity Type:Organization
Organization Name:KAREN POTACZEK, D.D.S., P.C.
Other - Org Name:SPENCER & LAKES REGIONAL ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTACZEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-262-7350
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4393
Mailing Address - Country:US
Mailing Address - Phone:712-262-7350
Mailing Address - Fax:712-262-7351
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4393
Practice Address - Country:US
Practice Address - Phone:712-262-7350
Practice Address - Fax:712-262-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1225468812Medicaid
IA1225468812Medicaid