Healthcare Provider Details

I. General information

NPI: 1053185702
Provider Name (Legal Business Name): DRSGM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10520 S 204TH ST STE C
GRETNA NE
68028-4185
US

IV. Provider business mailing address

10520 S 204TH ST STE C
GRETNA NE
68028-4185
US

V. Phone/Fax

Practice location:
  • Phone: 402-403-6007
  • Fax: 402-403-1243
Mailing address:
  • Phone: 402-403-6007
  • Fax: 402-403-1243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAYNA MATTOX
Title or Position: OWNER
Credential: DDS
Phone: 402-319-6688