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General NPI Number Information
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NPI Number | 1093465361
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Entity Type | Organization
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Legal Business Name | FREMONT DENTAL GROUP PC
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Dates
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Enumeration Date | 03/28/2022
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Last Update Date | 03/28/2022
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Provider Practice Location Address
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Address Line | 1435 E 23RD ST
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City | FREMONT
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State | NE
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Zip | 68025-2433
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Country | US
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Telephone | 402-727-9100
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Fax |
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Provider Business Mailing Address
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Address Line | 1435 E 23RD ST
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City | FREMONT
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State | NE
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Zip | 68025-2433
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Country | US
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Telephone | 402-727-9100
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Fax |
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Authorized Official
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Title or Position | LEAD OF CREDENTIALING
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Name | VICENTA REYES
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Credential |
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Telephone | 972-869-3789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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