Provider Demographics
NPI:1427591031
Name:PEDIATRIC DENTAL GROUP, PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP, PC
Other - Org Name:MY PEDIATRIC DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HAJEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-354-7077
Mailing Address - Street 1:1411 JFK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 J F KENNEDY DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3639
Practice Address - Country:US
Practice Address - Phone:402-291-6577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE70301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty