Provider Demographics
NPI:1033123336
Name:WAHOO DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WAHOO DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:GLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-443-5959
Mailing Address - Street 1:357 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-1920
Mailing Address - Country:US
Mailing Address - Phone:402-443-5959
Mailing Address - Fax:
Practice Address - Street 1:357 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1920
Practice Address - Country:US
Practice Address - Phone:402-443-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE62531223G0001X, 1223G0001X
NE66351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025583000Medicaid