Healthcare Provider Details

I. General information

NPI: 1467901405
Provider Name (Legal Business Name): BELLEVUE ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 LINCOLN RD STE 102
BELLEVUE NE
68005-2341
US

IV. Provider business mailing address

1004 LINCOLN RD STE 102
BELLEVUE NE
68005-2341
US

V. Phone/Fax

Practice location:
  • Phone: 402-250-9097
  • Fax:
Mailing address:
  • Phone: 402-250-9097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number7206
License Number StateNE

VIII. Authorized Official

Name: KYLE DAVID SMITH
Title or Position: MEMBER
Credential: D.D.S.
Phone: 402-250-9097