Individual
IAN JACOB FULLINFAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1026 WOODBURY AVE, COUNCIL BLUFFS, IA 51503-7915
(712) 201-8891
Mailing address
15711 LAKESIDE CIR, OMAHA, NE 68135-1103
(402) 917-0650
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
7932
NE
1223G0001X
General Practice Dentistry
Primary
DDS-10256
IA
390200000X
Student in an Organized Health Care Education/Training Program
13750
CT
Other
Enumeration date
04/11/2023
Last updated
10/16/2024
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