Provider Demographics
NPI:1407285844
Name:SMILE STATION PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SMILE STATION PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:HOHENSTEIN
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-330-5535
Mailing Address - Street 1:6801 S 180TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3264
Mailing Address - Country:US
Mailing Address - Phone:402-330-5535
Mailing Address - Fax:
Practice Address - Street 1:6801 S 180TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3264
Practice Address - Country:US
Practice Address - Phone:402-330-5535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6331122300000X
NE69301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1255697231Medicaid