Provider Demographics
NPI:1609846583
Name:IOWA ORAL AND MAXILLOFACIAL SURGEONS, PC
Entity Type:Organization
Organization Name:IOWA ORAL AND MAXILLOFACIAL SURGEONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:WEIRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-327-1647
Mailing Address - Street 1:1469 29TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1302
Mailing Address - Country:US
Mailing Address - Phone:515-223-6529
Mailing Address - Fax:515-223-5448
Practice Address - Street 1:1469 29TH ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1302
Practice Address - Country:US
Practice Address - Phone:515-223-6529
Practice Address - Fax:515-223-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA064471223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22178OtherMEDICARE PTAN
IA22178OtherMEDICARE PTAN