Provider Demographics
NPI:1326402470
Name:OMAHA ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:OMAHA ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:507-316-2205
Mailing Address - Street 1:5040 SO 153RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5067
Mailing Address - Country:US
Mailing Address - Phone:507-316-2205
Mailing Address - Fax:
Practice Address - Street 1:5040 SO 153RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5067
Practice Address - Country:US
Practice Address - Phone:507-316-2205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE288501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty