Healthcare Provider Details

I. General information

NPI: 1699193169
Provider Name (Legal Business Name): GENESIS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 A ST STE 105
LINCOLN NE
68510-4205
US

IV. Provider business mailing address

7001 A STREET SUITE 105
LINCOLN NE
68510-4205
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-5275
  • Fax: 402-483-5200
Mailing address:
  • Phone: 402-488-5275
  • Fax: 402-483-5200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY ELLEN GLENN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 402-488-5275