Provider Demographics
NPI:1093718553
Name:SCHNEIDER, JACK DOUGLASS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DOUGLASS
Last Name:SCHNEIDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 S 56TH ST
Mailing Address - Street 2:STE 3
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-1892
Mailing Address - Country:US
Mailing Address - Phone:402-423-2900
Mailing Address - Fax:402-423-2907
Practice Address - Street 1:5310 S 56TH ST
Practice Address - Street 2:STE 3
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-1892
Practice Address - Country:US
Practice Address - Phone:402-423-2900
Practice Address - Fax:402-423-2907
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470680876-00Medicaid
NE275900Medicare ID - Type Unspecified
NE470680876-00Medicaid