Provider Demographics
NPI:1629072954
Name:PEDODONTICS, PC
Entity Type:Organization
Organization Name:PEDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-330-5913
Mailing Address - Street 1:2514 S 119TH ST STE2
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144
Mailing Address - Country:US
Mailing Address - Phone:402-330-5913
Mailing Address - Fax:402-333-3190
Practice Address - Street 1:2514 S 119TH ST STE2
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-330-5913
Practice Address - Fax:402-333-3190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE51751223P0221X
NE60471223P0221X
NE34411223P0221X
NE65141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
470534372Medicare UPIN