Healthcare Provider Details

I. General information

NPI: 1760708218
Provider Name (Legal Business Name): DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 A STREET
LINCOLN NE
68510
US

IV. Provider business mailing address

4110 A STREET
LINCOLN NE
68510
US

V. Phone/Fax

Practice location:
  • Phone: 402-327-9400
  • Fax: 402-327-9401
Mailing address:
  • Phone: 402-327-9400
  • Fax: 402-327-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number25504
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6487
License Number StateNE

VIII. Authorized Official

Name: DR. DAVID J RALLIS
Title or Position: PRESIDENT/OWNER
Credential: M.D., D.D.S.
Phone: 507-358-0974