MEDICARE: MISSOURI VALLEY DENTAL GROUP, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437467628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI VALLEY DENTAL GROUP, LLC

Provider Business Mailing Address
First Line	:	11110 FORT ST STE 106&107
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68164-2183
Country	:	US
Telephone Number	:	402-492-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	11110 FORT ST STE 106&107
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68164-2183
Country	:	US
Telephone Number	:	402-492-8300
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE SECRETARY
Name	:	JEAN ANN KERGER
Credential	:
Telephone Number	:	402-492-8300

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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