Provider Demographics
NPI:1760708218
Name:DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:RALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:507-358-0974
Mailing Address - Street 1:4110 A STREET
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-327-9400
Mailing Address - Fax:402-327-9401
Practice Address - Street 1:4110 A STREET
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510
Practice Address - Country:US
Practice Address - Phone:402-327-9400
Practice Address - Fax:402-327-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE255041223S0112X
NE6487204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025849700Medicaid