Healthcare Provider Details

I. General information

NPI: 1588781306
Provider Name (Legal Business Name): SPECIALTY DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 W CENTER RD SUITE 76
OMAHA NE
68144-3962
US

IV. Provider business mailing address

12242 K PLZ SUITE 113
OMAHA NE
68137-2260
US

V. Phone/Fax

Practice location:
  • Phone: 402-334-8083
  • Fax: 402-334-0834
Mailing address:
  • Phone: 402-334-8083
  • Fax: 402-334-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberNE4332
License Number StateNE

VIII. Authorized Official

Name: MRS. MARSHA K. MCBRATNEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 402-334-8083