Healthcare Provider Details

I. General information

NPI: 1043133309
Provider Name (Legal Business Name): PEDIATRIC DENTAL SPECIALISTS OF GREATER NEBRASKA - LINCOLN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 PINE LAKE RD STE 250
LINCOLN NE
68516-5497
US

IV. Provider business mailing address

3901 PINE LAKE RD STE 250
LINCOLN NE
68516-5497
US

V. Phone/Fax

Practice location:
  • Phone: 402-423-3322
  • Fax:
Mailing address:
  • Phone: 402-423-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVE JOHNSON
Title or Position: COO
Credential:
Phone: 402-462-6557