Healthcare Provider Details

I. General information

NPI: 1164876637
Provider Name (Legal Business Name): PIONEER PERIODONTICS & IMPLANT DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 S 70TH ST STE #200
LINCOLN NE
68506-1571
US

IV. Provider business mailing address

1640 S 70TH ST STE #200
LINCOLN NE
68506-1571
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-7631
  • Fax: 402-483-1237
Mailing address:
  • Phone: 402-483-7631
  • Fax: 402-483-1237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: JOHN E RUTLDEGE
Title or Position: PERIODONTIST/OWNER
Credential: DDS,MS
Phone: 402-483-7631