Provider Demographics
NPI:1659435360
Name:OMNI DENTAL CENTRES, LLP
Entity Type:Organization
Organization Name:OMNI DENTAL CENTRES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-328-8573
Mailing Address - Street 1:1026 WOODBURY AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-7915
Mailing Address - Country:US
Mailing Address - Phone:712-328-8573
Mailing Address - Fax:712-328-0233
Practice Address - Street 1:1026 WOODBURY AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-7915
Practice Address - Country:US
Practice Address - Phone:712-328-8573
Practice Address - Fax:712-328-0233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNI DENTAL CENTRES, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-20
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA60291223G0001X
IA081321223G0001X
IA66141223G0001X
IA68551223G0001X
IA81321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0058560Medicaid
IA0241794Medicaid