MEDICARE: REM DDS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1376249151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REM DDS LLC

Provider Business Mailing Address
First Line	:	6606 S 168TH ST STE 100
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-5420
Country	:	US
Telephone Number	:	402-505-6843
Fax Number	:

Provider Business Practice Location Address
First Line	:	6865 PEARL RD STE 23
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-3616
Country	:	US
Telephone Number	:	402-505-6843
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	RIKKI LIEBERTH
Credential	:
Telephone Number	:	402-505-6843

Provider Enumeration Date	:	02/03/2023
Last Update Date	:	02/03/2023

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