Provider Demographics
NPI:1982781340
Name:EASTERN IOWA ORTHODONTICS
Entity Type:Organization
Organization Name:EASTERN IOWA ORTHODONTICS
Other - Org Name:KADAVY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-243-6622
Mailing Address - Street 1:314 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4436
Mailing Address - Country:US
Mailing Address - Phone:563-243-6622
Mailing Address - Fax:563-242-1484
Practice Address - Street 1:314 3RD AVE S
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4436
Practice Address - Country:US
Practice Address - Phone:563-243-6622
Practice Address - Fax:563-242-1484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074542Medicaid