Healthcare Provider Details

I. General information

NPI: 1285278028
Provider Name (Legal Business Name): OMAHA PERIODONTICS AND IMPLANT DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 N 129TH ST STE 200
OMAHA NE
68154-6110
US

IV. Provider business mailing address

624 N 129TH ST STE 200
OMAHA NE
68154-6110
US

V. Phone/Fax

Practice location:
  • Phone: 402-431-8688
  • Fax:
Mailing address:
  • Phone: 402-431-8688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ERICA E JASA
Title or Position: PERIODONTIST
Credential: DDS,MS
Phone: 402-431-8688