Provider Demographics
NPI:1063822401
Name:BLUE SKY DENTAL LLC
Entity Type:Organization
Organization Name:BLUE SKY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:F
Authorized Official - Last Name:SWIRCZEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-991-9423
Mailing Address - Street 1:2430 S 73RD ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2397
Mailing Address - Country:US
Mailing Address - Phone:402-991-9423
Mailing Address - Fax:402-991-9890
Practice Address - Street 1:2430 S 73RD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2397
Practice Address - Country:US
Practice Address - Phone:402-991-9423
Practice Address - Fax:402-991-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025997800Medicaid