Provider Demographics
NPI:1871648881
Name:BRENTWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:BRENTWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:OBENG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-597-2777
Mailing Address - Street 1:2605 SO 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124
Mailing Address - Country:US
Mailing Address - Phone:402-597-2777
Mailing Address - Fax:402-597-3643
Practice Address - Street 1:2605 SO 84TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124
Practice Address - Country:US
Practice Address - Phone:402-597-2777
Practice Address - Fax:402-597-3643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty