Provider Demographics
NPI:1558690545
Name:BELLEVUE ORAL AND MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:BELLEVUE ORAL AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:PREMIER ORAL AND MAXILLOFACIL SURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AFOLABI
Authorized Official - Middle Name:OLUFOLAHAN
Authorized Official - Last Name:OGUNLEYE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:402-708-6222
Mailing Address - Street 1:546 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-2632
Mailing Address - Country:US
Mailing Address - Phone:402-916-5800
Mailing Address - Fax:402-916-5900
Practice Address - Street 1:546 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-2632
Practice Address - Country:US
Practice Address - Phone:402-916-5800
Practice Address - Fax:402-916-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6642261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental