Healthcare Provider Details

I. General information

NPI: 1760626857
Provider Name (Legal Business Name): FACIAL DIMENSIONS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W KOENIG ST
GRAND ISLAND NE
68801-6556
US

IV. Provider business mailing address

710 W KOENIG ST
GRAND ISLAND NE
68801-6556
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-1172
  • Fax:
Mailing address:
  • Phone: 308-384-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4372
License Number StateNE

VIII. Authorized Official

Name: G A. PETERSON
Title or Position: PRESIDENT
Credential: D.D.S., M.D.
Phone: 308-384-1172