Healthcare Provider Details

I. General information

NPI: 1447279724
Provider Name (Legal Business Name): KORT ANDREW IGEL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 PACIFIC ST
OMAHA NE
68154-3507
US

IV. Provider business mailing address

12020 PACIFIC ST
OMAHA NE
68154-3507
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-1152
  • Fax: 402-330-3764
Mailing address:
  • Phone: 402-330-1152
  • Fax: 402-330-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5368
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: