Healthcare Provider Details

I. General information

NPI: 1932214475
Provider Name (Legal Business Name): TIBURON FAMILY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16919 AUDREY ST SUITE 40
OMAHA NE
68136
US

IV. Provider business mailing address

16919 AUDREY ST SUITE 40
OMAHA NE
68136
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-9413
  • Fax: 402-505-9704
Mailing address:
  • Phone: 402-932-9413
  • Fax: 402-505-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3417859922
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6576
License Number StateNE

VIII. Authorized Official

Name: DR. ROBERT H JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 402-932-9413