Provider Demographics
NPI:1912212804
Name:MONTCLAIR DENTAL, PC
Entity Type:Organization
Organization Name:MONTCLAIR DENTAL, PC
Other - Org Name:MONTCLAIR DENTAL ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-333-5337
Mailing Address - Street 1:13057 W CENTER ROAD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3723
Mailing Address - Country:US
Mailing Address - Phone:402-333-5337
Mailing Address - Fax:402-333-5346
Practice Address - Street 1:13057 W CENTER ROAD
Practice Address - Street 2:SUITE 15
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3723
Practice Address - Country:US
Practice Address - Phone:402-333-5337
Practice Address - Fax:402-333-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68491223G0001X
NE40811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty