Provider Demographics
NPI:1164686648
Name:UNTRAUER, JASON BRADFORD (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRADFORD
Last Name:UNTRAUER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-5999
Mailing Address - Fax:
Practice Address - Street 1:4014 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1053
Practice Address - Country:US
Practice Address - Phone:402-559-5999
Practice Address - Fax:402-559-3499
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25465122300000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE25465OtherNE LICENSE