Provider Demographics
NPI:1467553362
Name:PEDIATRIC DENTAL SPECIALISTS OF GREATER NEBRASKA, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS OF GREATER NEBRASKA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-462-6557
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68902-0667
Mailing Address - Country:US
Mailing Address - Phone:402-462-6557
Mailing Address - Fax:402-461-4479
Practice Address - Street 1:601 N ST JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68902-0667
Practice Address - Country:US
Practice Address - Phone:402-462-6557
Practice Address - Fax:402-461-4479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
NE6334122300000X
NE6199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025036700Medicaid