Healthcare Provider Details

I. General information

NPI: 1881608156
Provider Name (Legal Business Name): SOUTH OMAHA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 S 72ND ST
RALSTON NE
68127-2876
US

IV. Provider business mailing address

5360 S 72ND ST
RALSTON NE
68127-2876
US

V. Phone/Fax

Practice location:
  • Phone: 402-733-4441
  • Fax: 402-733-5863
Mailing address:
  • Phone: 402-733-4441
  • Fax: 402-733-5863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5826
License Number StateNE

VIII. Authorized Official

Name: DR. FRANK NORMAN VARON
Title or Position: OWNER
Credential: D.D.S.
Phone: 402-733-4441