=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427353168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHERRY HILL DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 01/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 249 CHERRY HILL BLVD SUITE 5
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68510-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-488-2383
-----------------------------------------------------
Fax | 402-488-2384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 249 CHERRY HILL BLVD SUITE 5
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68510-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-488-2383
-----------------------------------------------------
Fax | 402-488-2384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JERRY A KROEGER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 402-488-2383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3900
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------