Healthcare Provider Details

I. General information

NPI: 1497876684
Provider Name (Legal Business Name): JACOB LEE FIMPLE D.D.S., M.M.S.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18015 OAK ST STE A
OMAHA NE
68130-6093
US

IV. Provider business mailing address

18015 OAK ST STE A
OMAHA NE
68130-6093
US

V. Phone/Fax

Practice location:
  • Phone: 402-763-4929
  • Fax: 402-502-5990
Mailing address:
  • Phone: 402-763-4929
  • Fax: 402-502-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21622
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6675
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: