Provider Demographics
NPI:1245543842
Name:PRUITT, CHASE A (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:CHASE
Middle Name:A
Last Name:PRUITT
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 S 153RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5067
Mailing Address - Country:US
Mailing Address - Phone:402-881-7996
Mailing Address - Fax:
Practice Address - Street 1:5040 S 153RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5067
Practice Address - Country:US
Practice Address - Phone:402-881-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71271223S0112X
NE28850204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN850000159Medicare UPIN