Provider Demographics
NPI:1053760306
Name:FORMANEK, JOSEPH JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JAMES
Last Name:FORMANEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 SE DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-4553
Mailing Address - Country:US
Mailing Address - Phone:515-650-9390
Mailing Address - Fax:
Practice Address - Street 1:2409 SE DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4553
Practice Address - Country:US
Practice Address - Phone:515-650-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-092891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice