Healthcare Provider Details

I. General information

NPI: 1578777553
Provider Name (Legal Business Name): CHAD W. TOLLY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4830 SAINT PAUL AVE
LINCOLN NE
68504-2661
US

IV. Provider business mailing address

4830 SAINT PAUL AVE
LINCOLN NE
68504-2661
US

V. Phone/Fax

Practice location:
  • Phone: 402-466-2248
  • Fax: 402-466-3286
Mailing address:
  • Phone: 402-466-2248
  • Fax: 402-466-3286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6171
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: