Healthcare Provider Details

I. General information

NPI: 1477227551
Provider Name (Legal Business Name): WILLOW DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5709 NW RADIAL HWY
OMAHA NE
68104-4141
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 402-551-1757
  • Fax:
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-310-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LILY DAVIS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 918-998-0996