Provider Demographics
NPI:1073259685
Name:TWIN RIVERS DENTAL, PC
Entity Type:Organization
Organization Name:TWIN RIVERS DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:L
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-252-1190
Mailing Address - Street 1:12166 S 218TH ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-5947
Mailing Address - Country:US
Mailing Address - Phone:208-252-1190
Mailing Address - Fax:
Practice Address - Street 1:7333 N 277TH CIRCLE
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:NE
Practice Address - Zip Code:68064
Practice Address - Country:US
Practice Address - Phone:208-252-1190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty