Provider Demographics
NPI:1336319714
Name:SUMMIT DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:SUMMIT DENTAL ASSOCIATES
Other - Org Name:RAINBOW DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:V
Authorized Official - Last Name:STOAKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-333-3151
Mailing Address - Street 1:2503 S 140TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2315
Mailing Address - Country:US
Mailing Address - Phone:402-333-3151
Mailing Address - Fax:402-697-9244
Practice Address - Street 1:2503 S 140TH CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2315
Practice Address - Country:US
Practice Address - Phone:402-333-3151
Practice Address - Fax:402-697-9244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025568500Medicaid