1952623902 NPI number — DENTAL SPECIALTIES

Table of content: (NPI 1952623902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952623902 NPI number — DENTAL SPECIALTIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SPECIALTIES
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:
1952623902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14133 Q ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-895-1900
Provider Business Mailing Address Fax Number:
402-895-5726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14133 Q ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-895-1900
Provider Business Practice Location Address Fax Number:
402-895-5726
Provider Enumeration Date:
02/18/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAKES
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-895-1900

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6712 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 4879 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 6335 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10025232300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".