Healthcare Provider Details

I. General information

NPI: 1598243511
Provider Name (Legal Business Name): PEDIATRIC DENTAL SPECIALISTS OF GREATER NEBRASKA - OMAHA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 S 73RD ST STE 203
OMAHA NE
68124-2395
US

IV. Provider business mailing address

2410 S 73RD ST STE 203
OMAHA NE
68124-2395
US

V. Phone/Fax

Practice location:
  • Phone: 402-397-3377
  • Fax:
Mailing address:
  • Phone: 402-397-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAVID F JOHNSON III
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 402-397-3377