Healthcare Provider Details

I. General information

NPI: 1255697231
Provider Name (Legal Business Name): SMILE STATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17935 WELCH PLZ STE 104
OMAHA NE
68135-3596
US

IV. Provider business mailing address

17935 WELCH PLZ STE 104
OMAHA NE
68135-3596
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-5535
  • Fax: 402-330-5543
Mailing address:
  • Phone: 402-330-5535
  • Fax: 402-330-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6331
License Number StateNE

VIII. Authorized Official

Name: DR. JAMES BRYAN HOHENSTEIN
Title or Position: CEO
Credential: DDS
Phone: 402-330-5535