Healthcare Provider Details

I. General information

NPI: 1750456950
Provider Name (Legal Business Name): PEDERSEN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 A ST
SCHUYLER NE
68661-1927
US

IV. Provider business mailing address

1005 A ST
SCHUYLER NE
68661-1927
US

V. Phone/Fax

Practice location:
  • Phone: 402-352-5566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5633
License Number StateNE

VIII. Authorized Official

Name: DR. TODD LEROY PEDERSEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 402-352-5566