Provider Demographics
NPI:1790768018
Name:SAMBOL, ELIZABETH A
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:SAMBOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:SZELIGA
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8909 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-6161
Mailing Address - Country:US
Mailing Address - Phone:402-572-1120
Mailing Address - Fax:402-572-9059
Practice Address - Street 1:8909 GRANT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6161
Practice Address - Country:US
Practice Address - Phone:402-572-1120
Practice Address - Fax:402-572-9059
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5647OtherBLUECROSS BLUESHIELD
NE709166OtherUNITED CONCORDIA PPO
NE10025165800Medicaid