Provider Demographics
NPI:1891753067
Name:DESA, VALMONT P (MD, DDS)
Entity Type:Individual
Prefix:
First Name:VALMONT
Middle Name:P
Last Name:DESA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-5999
Mailing Address - Fax:402-559-3499
Practice Address - Street 1:988102 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-5999
Practice Address - Fax:402-559-3499
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22875204E00000X
NE58781223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557585Medicaid
NEI13486Medicare UPIN
NE47078557585Medicaid