Provider Demographics
NPI:1740747583
Name:PFOHL, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PFOHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 GLASS RD NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-2538
Mailing Address - Country:US
Mailing Address - Phone:319-294-8181
Mailing Address - Fax:319-261-8182
Practice Address - Street 1:4207 GLASS RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2538
Practice Address - Country:US
Practice Address - Phone:192-948-1813
Practice Address - Fax:319-261-8182
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09682390200000X
IADDS-096821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADDS-09682OtherSTATE LICENSE NUMBER