Provider Demographics
NPI:1700089513
Name:POTACZEK, KAREN (DDS)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:POTACZEK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4393
Mailing Address - Country:US
Mailing Address - Phone:712-262-7350
Mailing Address - Fax:712-262-7351
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4393
Practice Address - Country:US
Practice Address - Phone:712-262-7350
Practice Address - Fax:712-262-7351
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08697204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1700089513Medicaid
MN1700089513Medicaid