Provider Demographics
NPI:1740583640
Name:PEDERSEN, TODD L (DDS)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 228
Mailing Address - Street 2:
Mailing Address - City:SCHUYLER
Mailing Address - State:NE
Mailing Address - Zip Code:68661-1927
Mailing Address - Country:US
Mailing Address - Phone:402-352-5566
Mailing Address - Fax:402-352-5316
Practice Address - Street 1:1005 A ST
Practice Address - Street 2:
Practice Address - City:SCHUYLER
Practice Address - State:NE
Practice Address - Zip Code:68661-1927
Practice Address - Country:US
Practice Address - Phone:402-352-5566
Practice Address - Fax:402-352-5566
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE56331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025193700Medicaid
NE331105556OtherITIN