Healthcare Provider Details

I. General information

NPI: 1366213258
Provider Name (Legal Business Name): SEDILLO MOBILE DDS NE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5884 HIGH PASTURE DR
FORT CALHOUN NE
68023-8201
US

IV. Provider business mailing address

5884 HIGH PASTURE DR
FORT CALHOUN NE
68023-8201
US

V. Phone/Fax

Practice location:
  • Phone: 402-237-2163
  • Fax:
Mailing address:
  • Phone: 402-237-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA ANN OLIVARES
Title or Position: OFFICE MANAGER
Credential:
Phone: 712-326-4860