Provider Demographics
NPI:1871690842
Name:HEARTLAND ENDODONTIC SPECIALISTS, LLC
Entity Type:Organization
Organization Name:HEARTLAND ENDODONTIC SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-393-5050
Mailing Address - Street 1:615 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2821
Mailing Address - Country:US
Mailing Address - Phone:402-393-5050
Mailing Address - Fax:402-393-3401
Practice Address - Street 1:615 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2821
Practice Address - Country:US
Practice Address - Phone:402-393-5050
Practice Address - Fax:402-393-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE460446OtherUNITED CONCORDIA