Healthcare Provider Details

I. General information

NPI: 1790177020
Provider Name (Legal Business Name): DARYL E. MALENA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10838 OLD MILL RD STE 8
OMAHA NE
68154-2649
US

IV. Provider business mailing address

10838 OLD MILL RD STE 8
OMAHA NE
68154-2649
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3901
License Number StateNE

VIII. Authorized Official

Name: DR. DARYL E. MALENA
Title or Position: OWNER
Credential: DDS
Phone: 402-330-4100