Provider Demographics
NPI:1992962732
Name:EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:EASTERN IOWA ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-366-8277
Mailing Address - Street 1:4150 EDGEWOOD ROAD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-0609
Mailing Address - Country:US
Mailing Address - Phone:319-366-8277
Mailing Address - Fax:319-366-7091
Practice Address - Street 1:4150 EDGEWOOD ROAD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-0609
Practice Address - Country:US
Practice Address - Phone:319-366-8277
Practice Address - Fax:319-366-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA08986OtherBENJAMIN L. FULLER LICENSE NUMBER
IA1265727150OtherJAROM E. MAURER NPI
IA1689802910OtherBENJAMIN L. FULLER NPI
IA09173OtherJAROM E. MAURER LICENSE NUMBER