Healthcare Provider Details

I. General information

NPI: 1871541078
Provider Name (Legal Business Name): DERMATOLOGY SURGERY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N 96TH ST SUITE 201
OMAHA NE
68114-2497
US

IV. Provider business mailing address

909 N 96TH ST SUITE 201
OMAHA NE
68114-2497
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-4555
  • Fax:
Mailing address:
  • Phone: 402-330-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA KAY DILTS
Title or Position: ADMINISTRATOR
Credential:
Phone: 402-330-4555