1255737078 NPI number — PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY LLC

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 1255737078 NPI number — PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY LLC
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:
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:
1255737078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
416 VALLEY VIEW DRIVE
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
SCOTTSBLUFF
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
69361-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-633-1760
Provider Business Mailing Address Fax Number:
308-633-1762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 VALLEY VIEW DRIVE
Provider Second Line Business Practice Location Address:
SUITE 800
Provider Business Practice Location Address City Name:
SCOTTSBLUFF
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
69361-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-633-1760
Provider Business Practice Location Address Fax Number:
308-633-1762
Provider Enumeration Date:
11/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FOOTE
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
308-633-1760

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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