1154570745 NPI number — ADVANCED ENDODONTIC THERAPY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154570745 NPI number — ADVANCED ENDODONTIC THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED ENDODONTIC THERAPY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154570745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18015 OAK ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68130-6093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-763-4929
Provider Business Mailing Address Fax Number:
402-502-5990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18015 OAK ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-6093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-763-4929
Provider Business Practice Location Address Fax Number:
402-502-5990
Provider Enumeration Date:
09/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FIMPLE
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-763-4929

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  6675 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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