Ian Jacob Fullinfaw, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DDS-10256 Issued in IA

Practice address

1026 Woodbury Ave
Council Bluffs, IA 51503-7915

Phone

(712) 201-8891

NPI assigned

Apr 11, 2023

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1681171200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1729036800000",
    "number": "1861187205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15711 LAKESIDE CIR",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681351103",
            "telephone_number": "402-917-0650"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1026 WOODBURY AVE",
            "city": "COUNCIL BLUFFS",
            "state": "IA",
            "postal_code": "515037915",
            "telephone_number": "712-201-8891"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "14133 Q St",
            "address_purpose": "LOCATION",
            "city": "Omaha",
            "state": "NE",
            "postal_code": "681372600",
            "country_code": "US",
            "telephone_number": "402-506-5100",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FULLINFAW",
        "first_name": "IAN",
        "middle_name": "JACOB",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-04-11",
        "last_updated": "2024-10-16",
        "certification_date": "2024-10-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "CT",
            "license": "13750",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IA",
            "license": "DDS-10256",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NE",
            "license": "7932",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Andrew Frohardt
• Matthew F Fryzek, M.D.
• Full Circle Therapy Center, LLC
• Lisa Jane Fullenkamp, MA, CCC-SLP
• Brian Fuller, MS, LMSW, LMHP
• Daniel Eduardo Galeas Rodriguez, MD
• Annabel Galva, MD
• Linda Mabel Garcia-Dorta, MD
• Devon Garrean, LMHC
• Allysha Garthright, MA, LPC

• General Practice Dentistry in Council Bluffs, IA
• Providers in Council Bluffs, IA by specialty
• General Practice Dentistry in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2024; 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.