Provider Demographics
NPI:1396814182
Name:PARRA FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:PARRA FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-731-5423
Mailing Address - Street 1:5050 L STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68117
Mailing Address - Country:US
Mailing Address - Phone:402-731-5423
Mailing Address - Fax:402-884-5955
Practice Address - Street 1:5050 L STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68117
Practice Address - Country:US
Practice Address - Phone:402-731-5423
Practice Address - Fax:402-884-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2013-09-04
Deactivation Date:2013-08-08
Deactivation Code:
Reactivation Date:2013-09-04
Provider Licenses
StateLicense IDTaxonomies
NE122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025130200Medicaid
NE10025602000Medicaid