Healthcare Provider Details

I. General information

NPI: 1164686648
Provider Name (Legal Business Name): JASON BRADFORD UNTRAUER MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4014 LEAVENWORTH ST
OMAHA NE
68105-1053
US

IV. Provider business mailing address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-5999
  • Fax: 402-559-3499
Mailing address:
  • Phone: 402-559-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number25465
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number25465
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: