Healthcare Provider Details

I. General information

NPI: 1326423724
Provider Name (Legal Business Name): UNITED STATES AIR FORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD
OFFUTT AFB NE
68113-1043
US

IV. Provider business mailing address

2501 CAPEHART RD
OFFUTT AFB NE
68113-1043
US

V. Phone/Fax

Practice location:
  • Phone: 402-232-2273
  • Fax:
Mailing address:
  • Phone: 402-232-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number94297759922
License Number StateUT

VIII. Authorized Official

Name: DR. KEVIN BRENT WIEST
Title or Position: DENTIST
Credential: D.D.S.
Phone: 801-376-8189