1588781306 NPI number — SPECIALTY DENTAL CARE 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 1588781306 NPI number — SPECIALTY DENTAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY DENTAL CARE 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:
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:
1588781306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12242 K PLZ
Provider Second Line Business Mailing Address:
SUITE 113
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68137-2260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-334-8083
Provider Business Mailing Address Fax Number:
402-334-0834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12165 W CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 76
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68144-3962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-334-8083
Provider Business Practice Location Address Fax Number:
402-334-0834
Provider Enumeration Date:
03/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCBRATNEY
Authorized Official First Name:
MARSHA
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
402-334-8083

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  NE4332 , 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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