NPIMap

Organization Active NPI

Koentjoro & Le Dentistry PLC

  • General Practice Dentistry
  • Council Bluffs, IA
National Provider Identifier
1104494830
Registry record updated Jun 24, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
KOENTJORO & LE DENTISTRY PLC
Practice address
3617 Denmark Dr Ste 100
Council Bluffs, IA 51501-7756
Phone
(712) 326-3205
NPI assigned
Jun 17, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Aldo Koentjoro
Title
Owner
Phone
(712) 326-3205

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

3617 Denmark Dr Ste 100
Council Bluffs, IA 51501-7756

Mailing address

PO Box 3189
Syracuse, NY 13220-3189

National Provider Directory

National Provider Directory

Locations

3617 Denmark Dr
Ste 100
Council Bluffs, IA 51501
Phone (712) 326-3205

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623888000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624492800000",
    "number": "1104494830",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3189",
            "city": "SYRACUSE",
            "state": "NY",
            "postal_code": "132203189"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3617 DENMARK DR STE 100",
            "city": "COUNCIL BLUFFS",
            "state": "IA",
            "postal_code": "515017756",
            "telephone_number": "712-326-3205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KOENTJORO & LE DENTISTRY PLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-17",
        "last_updated": "2021-06-24",
        "certification_date": "2021-06-24",
        "status": "A",
        "authorized_official_last_name": "KOENTJORO",
        "authorized_official_first_name": "ALDO",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "712-326-3205"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Council Bluffs, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.