Provider Demographics
NPI:1134248578
Name:CEDAR RAPIDS ENDODONTICS PC
Entity type:Organization
Organization Name:CEDAR RAPIDS ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:319-365-1456
Mailing Address - Street 1:2750 1ST AVE NE
Mailing Address - Street 2:STE 410
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4845
Mailing Address - Country:US
Mailing Address - Phone:319-365-1456
Mailing Address - Fax:319-261-0118
Practice Address - Street 1:2750 1ST AVE NE
Practice Address - Street 2:STE 410
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4845
Practice Address - Country:US
Practice Address - Phone:319-365-1456
Practice Address - Fax:319-261-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA080901223E0200X
IA061751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty