Provider Demographics
NPI:1649211442
Name:MAIKON, RENEE ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:ELAINE
Last Name:MAIKON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:RENEE
Other - Middle Name:ELAINE
Other - Last Name:BRECKENRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1630 32ND STREET NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402
Mailing Address - Country:US
Mailing Address - Phone:319-362-8657
Mailing Address - Fax:319-362-1824
Practice Address - Street 1:1630 32ND STREET NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-362-8657
Practice Address - Fax:319-362-1824
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA55942OtherBLUE CROSS
IA2068189Medicaid
554537OtherUNITED CONCORDIA