Provider Demographics
NPI:1598998940
Name:R. W. ROUBAL, D.D.S., P.C.
Entity Type:Organization
Organization Name:R. W. ROUBAL, D.D.S., P.C.
Other - Org Name:ADVANCED DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHMID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-493-4175
Mailing Address - Street 1:11919 GRANT ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3475
Mailing Address - Country:US
Mailing Address - Phone:402-493-4175
Mailing Address - Fax:402-493-9273
Practice Address - Street 1:11919 GRANT ST
Practice Address - Street 2:SUITE 140
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3475
Practice Address - Country:US
Practice Address - Phone:402-493-4175
Practice Address - Fax:402-493-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4339261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6408610001Medicare NSC