Provider Demographics
NPI:1477201697
Name:JEPPESEN, ADDISON BLAIR (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ADDISON
Middle Name:BLAIR
Last Name:JEPPESEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13126 WEIR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1840
Mailing Address - Country:US
Mailing Address - Phone:402-996-0736
Mailing Address - Fax:
Practice Address - Street 1:10274 S 71ST ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68133-2659
Practice Address - Country:US
Practice Address - Phone:402-339-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE7822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program