Provider Demographics
NPI:1851302178
Name:KIMBALL & BEECHER WATERLOO PLLC
Entity Type:Organization
Organization Name:KIMBALL & BEECHER WATERLOO PLLC
Other - Org Name:KIMBALL AND BEECHER FAMILY DENTISTRY PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXEC. DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-235-6287
Mailing Address - Street 1:4015 HURST DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701
Mailing Address - Country:US
Mailing Address - Phone:319-235-6287
Mailing Address - Fax:319-235-6740
Practice Address - Street 1:4015 HURST DRIVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701
Practice Address - Country:US
Practice Address - Phone:319-235-6287
Practice Address - Fax:319-235-6740
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBALL AND BEECHER FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1851302178Medicaid