Provider Demographics
NPI:1326419540
Name:PLAZA RIDGE DENTAL
Entity Type:Organization
Organization Name:PLAZA RIDGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-223-4140
Mailing Address - Street 1:110 EASTSIDE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-3480
Mailing Address - Country:US
Mailing Address - Phone:402-223-4140
Mailing Address - Fax:402-228-1762
Practice Address - Street 1:110 EASTSIDE BLVD
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-3480
Practice Address - Country:US
Practice Address - Phone:402-223-4140
Practice Address - Fax:402-228-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6167261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental