Provider Demographics
NPI:1467969378
Name:BS DENTISTRY PC
Entity Type:Organization
Organization Name:BS DENTISTRY PC
Other - Org Name:SUDMAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:GALEN
Authorized Official - Last Name:SUDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:773-597-8863
Mailing Address - Street 1:220 N 89TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4072
Mailing Address - Country:US
Mailing Address - Phone:773-597-8863
Mailing Address - Fax:
Practice Address - Street 1:220 N 89TH ST STE 203
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4072
Practice Address - Country:US
Practice Address - Phone:773-597-8863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7064261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental