Healthcare Provider Details

I. General information

NPI: 1861480568
Provider Name (Legal Business Name): VINCENT JOHN TAKACS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD STE1I16 OFFUTT AFB
OFFUTT A F B NE
68113-1043
US

IV. Provider business mailing address

2805 LEIGH LN
PAPILLION NE
68133-3377
US

V. Phone/Fax

Practice location:
  • Phone: 402-232-9183
  • Fax: 402-294-9250
Mailing address:
  • Phone: 402-884-7394
  • Fax: 402-294-9250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00006635
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: