Provider Demographics
NPI:1255697231
Name:SMILE STATION
Entity type:Organization
Organization Name:SMILE STATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:HOHENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-330-5535
Mailing Address - Street 1:17935 WELCH PLZ STE 104
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3596
Mailing Address - Country:US
Mailing Address - Phone:402-330-5535
Mailing Address - Fax:402-330-5543
Practice Address - Street 1:17935 WELCH PLZ STE 104
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3596
Practice Address - Country:US
Practice Address - Phone:402-330-5535
Practice Address - Fax:402-330-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE63311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025993900Medicaid