1750456950 NPI number — PEDERSEN DENTAL

Table of content: (NPI 1750456950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750456950 NPI number — PEDERSEN DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDERSEN DENTAL
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:
1750456950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 A ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHUYLER
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68661-1927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 A ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHUYLER
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68661-1927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-352-5566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEDERSEN
Authorized Official First Name:
TODD
Authorized Official Middle Name:
LEROY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-352-5566

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5633 , 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)

  • Identifier: 05193 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 100251937-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".