MEDICARE: BELLEVUE ORAL AND MAXILLOFACIAL SURGERY

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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	7206	NE

General Provider Information

NPI Number	:	1467901405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLEVUE ORAL AND MAXILLOFACIAL SURGERY

Provider Business Mailing Address
First Line	:	1004 LINCOLN RD STE 102
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-2341
Country	:	US
Telephone Number	:	402-250-9097
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 LINCOLN RD STE 102
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-2341
Country	:	US
Telephone Number	:	402-250-9097
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	KYLE DAVID SMITH
Credential	:	D.D.S.
Telephone Number	:	402-250-9097

Provider Enumeration Date	:	10/03/2016
Last Update Date	:	10/03/2016

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