1104158948 NPI number — AA OMAHA EMERGECNY DENTAL CARE USA INC

Table of content: (NPI 1104158948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104158948 NPI number — AA OMAHA EMERGECNY DENTAL CARE USA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AA OMAHA EMERGECNY DENTAL CARE USA INC
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:
1104158948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1338 N 143RD AVENUE CIR
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:
68154-5108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-597-1186
Provider Business Mailing Address Fax Number:
402-332-4629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 S 84TH 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:
68124-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-926-4411
Provider Business Practice Location Address Fax Number:
402-393-2902
Provider Enumeration Date:
02/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
OBENG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
402-597-1186

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5964 , 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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