Provider Demographics
NPI:1386669133
Name:NORTH PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:NORTH PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-633-1760
Mailing Address - Street 1:416 VALLEY VIEW DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1486
Mailing Address - Country:US
Mailing Address - Phone:308-633-1760
Mailing Address - Fax:308-633-1762
Practice Address - Street 1:416 VALLEY VIEW DR
Practice Address - Street 2:SUITE 800
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1486
Practice Address - Country:US
Practice Address - Phone:308-633-1760
Practice Address - Fax:308-633-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid