Provider Demographics
NPI:1174862684
Name:SUPERIOR FAMILY DENTAL 107TH
Entity type:Organization
Organization Name:SUPERIOR FAMILY DENTAL 107TH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-391-1047
Mailing Address - Street 1:10730 PACIFIC ST
Mailing Address - Street 2:STE105
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4799
Mailing Address - Country:US
Mailing Address - Phone:402-391-1047
Mailing Address - Fax:402-391-0309
Practice Address - Street 1:10730 PACIFIC ST
Practice Address - Street 2:STE105
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4799
Practice Address - Country:US
Practice Address - Phone:402-391-1047
Practice Address - Fax:402-391-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4294261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental