Healthcare Provider Details

I. General information

NPI: 1851645303
Provider Name (Legal Business Name): LARRY DALLAS OWENS DH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART ROAD
OFFUTT AFB NE
68113
US

IV. Provider business mailing address

2501 CAPEHART RD # NE
OFFUTT AFB NE
68113-1043
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-3212
  • Fax:
Mailing address:
  • Phone: 402-294-3212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number956
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: