Healthcare Provider Details

I. General information

NPI: 1134493083
Provider Name (Legal Business Name): CHIDREN'S DENTISTRY OF SOUTH OMAHA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 OAK ST
OMAHA NE
68105-3727
US

IV. Provider business mailing address

2424 OAK ST
OMAHA NE
68105-3727
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-5553
  • Fax: 402-932-5557
Mailing address:
  • Phone: 402-932-5553
  • Fax: 402-932-5557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MAGDALENA EVANS
Title or Position: SR CREDENTIALING SPECIALIST
Credential:
Phone: 720-603-4800