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General NPI Number Information
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NPI Number | 1154750677
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY, P.C.
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Dates
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Enumeration Date | 11/05/2013
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Last Update Date | 12/12/2018
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Provider Practice Location Address
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Address Line | 3901 PINE LAKE RD STE 250
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City | LINCOLN
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State | NE
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Zip | 68516-5497
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Country | US
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Telephone | 402-423-3322
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Fax |
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Provider Business Mailing Address
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Address Line | 3901 PINE LAKE RD STE 250
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City | LINCOLN
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State | NE
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Zip | 68516-5497
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Country | US
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Telephone | 402-423-3322
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. BRENT D JOHNSON
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Credential | DDS
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Telephone | 402-423-3322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6566
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License Number State | NE
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