Healthcare Provider Details

I. General information

NPI: 1457400681
Provider Name (Legal Business Name): SOUTH LINCOLN PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6030 VILLAGE DR SUITE 100
LINCOLN NE
68516
US

IV. Provider business mailing address

6030 VILLAGE DR SUITE 100
LINCOLN NE
68516
US

V. Phone/Fax

Practice location:
  • Phone: 402-328-2900
  • Fax: 402-421-6661
Mailing address:
  • Phone: 402-328-2900
  • Fax: 402-421-6661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6244
License Number StateNE

VIII. Authorized Official

Name: DR. SCOTT ALAN HAMILTON
Title or Position: MEMBER
Credential: DDS
Phone: 402-770-3575