Healthcare Provider Details

I. General information

NPI: 1669834693
Provider Name (Legal Business Name): GREAT PLAINS DENTAL SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N 90TH ST
OMAHA NE
68114-2821
US

IV. Provider business mailing address

615 N 90TH ST
OMAHA NE
68114-2821
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-4100
  • Fax: 402-330-4103
Mailing address:
  • Phone: 402-330-4100
  • Fax: 402-330-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: ROBERT CLINE JR.
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 402-330-4100