MEDICARE: GV DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7221	NE
2	1223G0001X	General Practice Dentistry	4639	NE

General Provider Information

NPI Number	:	1205389301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GV DENTAL, LLC

Provider Business Mailing Address
First Line	:	1605 E MILITARY AVE
Second Line	:
City	:	FREMONT
State	:	NE
Zip	:	68025-5463
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 E MILITARY AVE
Second Line	:
City	:	FREMONT
State	:	NE
Zip	:	68025-5463
Country	:	US
Telephone Number	:	402-721-8770
Fax Number	:

Authorized Official
Title or Position	:	DR./ OWNER
Name	:	DR. JUSTIN S GUFFORD
Credential	:	DDS
Telephone Number	:	402-721-8770

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	09/22/2016

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