Provider Demographics
NPI:1841324084
Name:FORT DODGE ORAL AND MAXILLOFACIAL SURGERY LLP
Entity type:Organization
Organization Name:FORT DODGE ORAL AND MAXILLOFACIAL SURGERY LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHRAUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-576-8727
Mailing Address - Street 1:804 KENYON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5746
Mailing Address - Country:US
Mailing Address - Phone:515-576-8727
Mailing Address - Fax:515-576-7076
Practice Address - Street 1:804 KENYON RD
Practice Address - Street 2:STE 120
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5742
Practice Address - Country:US
Practice Address - Phone:515-576-8727
Practice Address - Fax:515-576-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1165050Medicaid
IA0438101Medicaid
IA1095471Medicaid
IAV00527Medicare UPIN
I11944Medicare PIN
IA1165050Medicaid
IA0438101Medicaid
IAT00975Medicare UPIN
I12384Medicare PIN