Provider Demographics
NPI:1215006747
Name:HERMANSON ORTHODONTICS P.C.
Entity type:Organization
Organization Name:HERMANSON ORTHODONTICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-752-6458
Mailing Address - Street 1:233 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-5411
Mailing Address - Country:US
Mailing Address - Phone:641-752-6458
Mailing Address - Fax:
Practice Address - Street 1:233 N 13TH ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-5411
Practice Address - Country:US
Practice Address - Phone:641-752-6458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA79421223X0400X
IA57711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0097741Medicaid