Healthcare Provider Details

I. General information

NPI: 1154257376
Provider Name (Legal Business Name): JEREMY QUACKENBUSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 DODGE ST
OMAHA NE
68114-4113
US

IV. Provider business mailing address

16413 SANDSTONE PLZ APT 1602
OMAHA NE
68116-4384
US

V. Phone/Fax

Practice location:
  • Phone: 402-552-7775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8192
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: