MEDICARE: KINGSLEY 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	122300000X	Dentist

General Provider Information

NPI Number	:	1376978668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGSLEY DENTAL LLC

Provider Business Mailing Address
First Line	:	3015 N 90TH ST STE 2
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-4713
Country	:	US
Telephone Number	:	402-571-0475
Fax Number	:	402-571-2932

Provider Business Practice Location Address
First Line	:	3015 N 90TH ST STE 2
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-4713
Country	:	US
Telephone Number	:	402-571-0475
Fax Number	:	402-571-2932

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DORIE LIPPOLD
Credential	:
Telephone Number	:	402-571-0475

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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Directions to “KINGSLEY DENTAL LLC ” Practice Location

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