Provider Demographics
NPI:1437252053
Name:WEST MAPLE DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:WEST MAPLE DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:M
Authorized Official - Last Name:SECOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-491-3100
Mailing Address - Street 1:14270 WEST MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164
Mailing Address - Country:US
Mailing Address - Phone:402-491-3100
Mailing Address - Fax:402-445-4094
Practice Address - Street 1:14270 WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164
Practice Address - Country:US
Practice Address - Phone:402-491-3100
Practice Address - Fax:402-445-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE59421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025250800Medicaid