Provider Demographics
NPI:1710390125
Name:KUCIREK, CARLA (DDS)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:KUCIREK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:GROSSKLAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 E SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-1711
Mailing Address - Country:US
Mailing Address - Phone:712-623-5404
Mailing Address - Fax:712-623-5231
Practice Address - Street 1:1700 E SUMMIT ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1711
Practice Address - Country:US
Practice Address - Phone:712-623-5404
Practice Address - Fax:712-623-5404
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09081122300000X
IA09081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1013215805Medicaid