Provider Demographics
NPI:1023179959
Name:JEPPESEN, MICAH TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:TODD
Last Name:JEPPESEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10274 S 71ST ST
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68133
Mailing Address - Country:US
Mailing Address - Phone:402-339-2501
Mailing Address - Fax:402-339-2503
Practice Address - Street 1:10274 S 71ST ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68133
Practice Address - Country:US
Practice Address - Phone:402-339-2501
Practice Address - Fax:402-339-2503
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE61011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47083321900Medicaid