Healthcare Provider Details

I. General information

NPI: 1144621996
Provider Name (Legal Business Name): MOBILE DENTAL CARE OF NEBRASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S 135TH AVE
OMAHA NE
68144-2424
US

IV. Provider business mailing address

12910 SHELBYVILLE RD STE 300
LOUISVILLE KY
40243-2404
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-2441
  • Fax: 502-254-4069
Mailing address:
  • Phone: 502-244-2441
  • Fax: 502-254-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DELIA RITTER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 502-244-2441