Provider Demographics
NPI:1235606773
Name:EDMINSTEN, ETHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:EDMINSTEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S 38TH ST APT 255
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3386
Mailing Address - Country:US
Mailing Address - Phone:505-702-4431
Mailing Address - Fax:
Practice Address - Street 1:4400 EMILE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-0600
Practice Address - Country:US
Practice Address - Phone:402-559-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist