=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972860419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TODAY'S DENTAL TRANQUILITY PARK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2012
-----------------------------------------------------
Last Update Date | 08/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12322 EMMET ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68164-4267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-496-9950
-----------------------------------------------------
Fax | 402-496-9778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12322 EMMET ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68164-4267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-496-9950
-----------------------------------------------------
Fax | 402-496-9778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER DDS
-----------------------------------------------------
Name | DR. BRENT J RISING
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 402-496-9950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 6819
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5480
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------