Healthcare Provider Details

I. General information

NPI: 1063073898
Provider Name (Legal Business Name): SOFIA IRIBARREN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 DODGE ST
OMAHA NE
68114-4113
US

IV. Provider business mailing address

8200 DODGE ST
OMAHA NE
68114-4113
US

V. Phone/Fax

Practice location:
  • Phone: 402-836-9785
  • Fax: 402-552-7765
Mailing address:
  • Phone: 515-267-0737
  • Fax: 402-836-9785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8047
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS-09997
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8047
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS-09997
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-09997
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: