Healthcare Provider Details

I. General information

NPI: 1023179959
Provider Name (Legal Business Name): MICAH TODD JEPPESEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10274 S 71ST ST
PAPILLION NE
68133
US

IV. Provider business mailing address

10274 S 71ST ST
PAPILLION NE
68133
US

V. Phone/Fax

Practice location:
  • Phone: 402-339-2501
  • Fax: 402-339-2503
Mailing address:
  • Phone: 402-339-2501
  • Fax: 402-339-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6101
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: