Provider Demographics
NPI:1033515903
Name:AESTHETIC & FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:AESTHETIC & FAMILY DENTISTRY LLC
Other - Org Name:AESTHETIC & FAMILY DENTISTRY:CAMERON LARRY A DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-293-1234
Mailing Address - Street 1:505 CORNHUSKER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-7911
Mailing Address - Country:US
Mailing Address - Phone:402-293-1234
Mailing Address - Fax:402-293-9364
Practice Address - Street 1:505 CORNHUSKER RD STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-7911
Practice Address - Country:US
Practice Address - Phone:402-293-1234
Practice Address - Fax:402-293-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1223G0001XMedicaid