Provider Demographics
NPI:1629158365
Name:UNMC COLLEGE OF DENTISTRY
Entity Type:Organization
Organization Name:UNMC COLLEGE OF DENTISTRY
Other - Org Name:PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT DEAN OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-472-3492
Mailing Address - Street 1:40TH AND HOLDREGE
Mailing Address - Street 2:ROOM 2106B
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68583-0740
Mailing Address - Country:US
Mailing Address - Phone:402-472-3492
Mailing Address - Fax:402-472-5290
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:2ND FLOOR SPC CHILDREN'S HOSPITAL
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-559-6100
Practice Address - Fax:402-552-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025084700Medicaid
IA2956599Medicaid