1710601422 NPI number — PEARL DENTISTRY OMAHA, LLC

Table of content: (NPI 1710601422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710601422 NPI number — PEARL DENTISTRY OMAHA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEARL DENTISTRY OMAHA, 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:
1710601422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7302 GILES RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA VISTA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68128-5902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-218-4220
Provider Business Mailing Address Fax Number:
402-218-4290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7302 GILES RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA VISTA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68128-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-218-4220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
202-812-9626

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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