Provider Demographics
NPI:1578777553
Name:TOLLY, CHAD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:W
Last Name:TOLLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 SAINT PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-2661
Mailing Address - Country:US
Mailing Address - Phone:402-466-2248
Mailing Address - Fax:402-466-3286
Practice Address - Street 1:4830 SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-2661
Practice Address - Country:US
Practice Address - Phone:402-466-2248
Practice Address - Fax:402-466-3286
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5077227600Medicaid
NE4706364-55-00Medicaid