Provider Demographics
NPI:1629354667
Name:ROBERT F. COLWELL JR, DDS, PC
Entity Type:Organization
Organization Name:ROBERT F. COLWELL JR, DDS, PC
Other - Org Name:SOUTHROADS DENTAL &/OR DREAM DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FRAZIER
Authorized Official - Last Name:COLWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-733-6066
Mailing Address - Street 1:712 FORT CROOK RD N
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-4558
Mailing Address - Country:US
Mailing Address - Phone:402-733-6066
Mailing Address - Fax:402-733-0899
Practice Address - Street 1:712 FORT CROOK RD N
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-4558
Practice Address - Country:US
Practice Address - Phone:402-733-6066
Practice Address - Fax:402-733-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6236261QD0000X
IA8073261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025204800Medicaid
IA15558428003Medicaid